COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX641 26986 
RC1 54  .M83  Leprosy,  by  Prince  A 


RECAP 


RCI5H- 


M83 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/leprosyOOmorr 


Leprosy 


PRINCE  A.   MORROW 

NEW  YORK 


REPRINTED   FROM 

Twentieth  CENTrRY  Practice  of  Medicine 
Vol.  XVIII. 


NEW  YORK 
WII^LIAM  WOOD  &  COMPANY 

PUBLISHERS 
1899. 


l?Ci^^ 


or)<^-3 


COLUMBIA    UNIVERSITY 
EDWARD   G.  JANEWAY 
MEMORIAL  LIBRARY 


LEPROSY. 


BY 


PRINCE  A.  MORROW. 


>"EW  YORK. 


Vol.  XVIII.— 26 


LEPROSY. 


Syno77yms.—liGpTa;  Elephantiasis  Grgecorum;  Leontiasis,  Saty- 
riasis; Frencli,  Lepre;  German,  Aussatz;  Norwegian,  Spedalskbed; 
Spanish,  Elefantiasis  de  los  Griegos;  Italian,  Elefantiasis  dei  Greci' 
Lepra,  Lebbre;  Latin,  Lepra  vera.  Elephantiasis;  Hebrew,  Zaraath 
(Tsaraath);  Sanscrit,  Kushtha;  Egyptian,  Uchetu. 

Z>e/?H7w«.— Leprosy  (from  Greek,  /li-,o«)  is  a  chronic  infectious 
disease  caused  by  the  bacillus  leprae,  characterized  by  erythematous 
and  pigmentary  changes  in  the  skin  and  the  production  of  tubercular 
nodules  containing  bacilli  in  the  cutaneous  tissues  and  mucous  mem- 
branes, and  by  irritative  and  degenerative  changes  in  the  nerves, 
with  implication  of  the  lymphatic  ganglia  and  internal  viscera  and 
the  supervention  of  a  profound  cachexia  which  leads  to  a  fatal  termi- 
nation. 

Types  of  Leprosy. 

The  bacilli  of  leprosy,  like  the  germs  of  other  infectious  diseases, 
when  they  have  gained  access  to  the  organism,  affect  particular  struc- 
tures and  spread  from  one  organ  to  another  along  certain  definite 
tracts,  producing  changes  in  the  tissues  which  are  characteristic  and 
peculiar  to  the  morbid  process.  These  changes  consist  of  diffuse 
or  circumscribed  infiltrations,  and  the  clinical  picture  varies  accord- 
ing to  the  localization  of  the  lesions  in  the  integument  or  in  the 
nerves. 

Two  principal  forms  of  leprosy  are  recognized.  When  there  is  a 
determination  of  the  morbid  process  towards  the  cutaneous  and  mu- 
cous membranes  in  the  shape  of  macules  and  nodules,  it  is  termed 
tubercular  or  tegmnentary ;  when  it  is  centred  upon  the  peripheral 
nerves,  it  is  termed  ancesthetic,  trophoneurotic,  or  nerve  leprosy.  These 
two  forms,  although  etiologically  identical,  exhibit  marked  differences 
in  their  objective  characters,  mode  of  evolution,  and  duration. 

In  tubercular  leprosy  the  predominating  lesions  are  nodular  infil- 
trations, termed  tubercles  or  lepromata,  in  the  skin,  mucous  mem- 
branes, and  other  organs;  the  course  of  this  form  is  more  rapid,  and 
the  average  duration  of  life  is  from  five  to  fifteen  years. 

Anaesthetic  leprosy  is  characterized  by  degenerative  changes  in 


404  MORROW — LErROSY. 

the  nerves,  an?estliesia,  atrophy,  and  mutilation  of  the  extremities ;  its 
course  is  slower,  and  the  duration  of  life  may  be  prolonged  to  fifteen 
or  twenty  years  or  longer. 

As  marks  of  differentiation  it  may  be  said  that  the  development  of 
tubercles  constitutes  the  distinctive  sign  of  the  tubercular  form,  while 
insensibility  and  atrophy  are  the  distinguishing  features  of  nerve 
leprosy.  While  both  forms  almost  invariably  proceed  to  a  fatal  ter- 
mination, both  are  susceptible  of  spontaneous  cure— the  anaesthetic 
form  rarely  and  the  tubercular  form  still  more  exceptionally. 

The  division  of  leprosy  into  two  principal  forms,  according  to  the 
most  prominent  symptoms  exhibited  by  each,  was  recognized  by  the 
early  writers,  and  this  classification  is  now  practically  universal. 
Certain  writers  have  attempted  to  differentiate  still  further  the  maui- 
festations  of  the  disease  by  the  employment  of  terms  indicating  a 
single  symptom.  Thus  Kaposi  and  others  describe  a  macular  form. 
This  cannot,  however,  be  recognized  as  constituting  a  distinct  form 
or  type  of  leprosy.  Macules  simply  represent  a  phase  in  the  evolu- 
tion of  the  malady  common  to  both  the  tubercular  and  anaesthetic 
forms  and  do  not  exist  independently,  but  are  always  associated 
sooner  or  later  with  tubercular  or  nerve  manifestations. 

That  the  above  division  of  leprosy  into  two  forms  is  to  a  certain 
extent  arbitrary  is  evident  from  the  fact  that  the  typical  features  of 
both  forms  may  coexist  in  the  same  individual,  thus  establishing  their 
pathological  unity.  In  a  certain  proportion  of  cases  there  is  a  com- 
bination of  both  tegumentary  and  nerve  lesions,  constituting  what 
is  termed  the  mixed  or  complete  type  of  leprosy. 

ETIOLOGY. 

At  the  present  time  there  is  a  general  consensus  of  opinion  among 
medical  men  that  the  vast  array  of  functional  disorders  and  organic 
changes  met  with  in  leprosy  are  caused  by  the  introduction  into  the 
human  body  of  a  specific  microorganism,  the  bacillus  leprae.  The 
fact  that  this  organism  is  invariably  found  in  the  body  of  lepers,  and 
nowhere  else,  would  seem  to  establish  the  relation  of  cause  and  effect 
between  the  presence  of  the  bacilli  and  the  production  of  the  symp- 
toms peculiar  to  the  disease.  It  must  be  admitted,  however,  that  the 
chain  of  evidence  which  connects  the  bacillus  with  the  causation  of 
leprosy  is  not  so  complete  as  in  the  case  of  certain  other  parasitic 
diseases,  as  for  example  tuberculosis  and  anthrax. 

The  rigorous  conditions  demanded  by  the  modern  scientific  mind 
before  we  are  authorized  to  affirm  that  the  disease  is  of  parasitic 
origin,  produced  by  the  introduction  into  the  organism  of  a  patho- 


ETIOLOGY.  405 

genie  microbe,  liave  not  been  complied  witli.     These  necessary  con- 
ditions are : 

1 .  Tliat  tlie  specific  microbe  should  be  found  in  the  diseased  tissues. 

2.  That  the  microbe  should  be  capable  of  being  cultivated  outside 
the  human  body. 

3.  That  when  the  product  of  pure  cultures  is  inoculated  into  the 
same  species  from  which  it  was  derived,  it  should  produce  the  iden- 
tical disease. 

Since  the  bacillus  has  not  been  successfully  cultivated  or  inoculated 
into  animals,  the  scientific  proof  of  its  pathological  role  has  not  been 
demonstrated.  Nevertheless,  it  is  generally  conceded  that  the  theory 
of  its  pathogenic  action  is  based  upon  sufficient  histological  and  clini- 
cal evidence.  This  evidence  has  been  formulated  by  Neisser  as  fol- 
lows : 

The  constant  presence  of  the  bacillus  in  all  cases  which  exhibit  un- 
doubted clinical  evidence  of  leprosy ;  its  localization  in  the  diseased 
foci  of  the  organism,  so  that  every  symptom  of  leprosy  may  be  cer- 
tainly referred  to  the  bacillary  focus  existing  in  situ  or  at  a  distance ; 
the  correlation  which  exists  between  the  cellular  alterations  within 
the  cells  and  the  bacilli;  the  fact  that  these  bacilli  present  charac- 
ters absolutely  specific,  and  that  leprosy  possesses  all  the  attributes 
and  joarticularly  the  mode  of  propagation  of  bacillary  diseases  pecu- 
liar to  the  human  race  and  transmitted  from  man  to  man.  All  these 
considerations  admit  of  no  doubt  that  the  bacillus  of  Hansen  is  the 
unique  and  necessary  pathogenic  agent  of  leprosy. 

The  etiological  views  of  writers  on  leprosy  before  the  discovery  of 
Hansen's  bacillus  have  now  only  an  historical  interest.  How  various, 
diverse,  and  even  contradictory  these  views  were  is  apparent  from  the 
fact  that  at  one  time  the  origin  of  leprosy  was  attributed  to  divine 
wrath  as  a  i^unishment  for  sin,  at  another  time  to  divine  favor,  secur- 
ing for  the  sufferers  religious  honors. 

Yiewed  from  the  standpoint  of  our  more  advanced  knowledge,  we 
look  upon  these  various  theories  of  the  origin  of  leprosy  as  only  the 
speculations  of  human  ignorance,  and  yet  many  of  the  theories  which 
had  been  advanced  are  not  only  interesting,  but  also  extremely  valu- 
able, as  they  indicate  clearly  the  conditions  under  which  leprosy  ordi- 
narily occurs. 

The  causes  of  leprosy  have  been  variously  ascribed  to  malaria, 
dampness  and  humidity,  uncleanly  habits,  filth  and  overcrowding, 
sudden  changes  of  temperature,  etc.  Dr.  Tilbury  Fox,  writing  in 
1868,  says  the  cause  of  leprosy  is  probably  a  mixed  one.  It  is  a  com- 
bination especially  of  bad  hygiene  exhibited  in  damp  dwellings,  putrid 
and  innutritions  food,  and  a  malarial  climate.     While  the  pathogenic 


406 


MORROW — LEPROSY. 


agent  of  leprosj-  escaped  detection,  there  is  no  doubt  that  the  causes 
alleged  by  these  observers  favor  the  propagation  of  the  disease  and 
to-day  are  recognized  as  powerful  predisposiug  factors. 


The  Bacillus  Leprae. 

The  bacillus  of  leprosy,  discovered  by  Hansen  in  1874,  is,  as  above 
intimated,  now  generally  regarded  as  the  essential  cause  of  leprosy. 
In  tubercular  leprosy  it  is  present  in  enormous  numbers ;  in  lepra 


Fig.  1.— Bacilli  Leprae.     (From  a  photograph  by  Dr.  J.  A.  Fordyee.) 

nervosa  it  is  normally  present  in  relatively  small  numbers.  It  has 
been  claimed  by  Kaposi,  Petrini,  and  others  that  it  may  be  absent 
even  in  well-marked  cases  of  tubercular  leprosy.  This  paradox  is 
explained  in  various  ways.  It  is  a  known  fact  that  under  certain  un- 
determined conditions  the  parasite  stains  very  poorly  and  decolorizes 
rapidly,  so  that  the  technique  may  still  be  regarded  as  faulty.  The 
failure  of  bacteriological  researches  to  demonstrate  the  presence  of 
bacilli  in  two  cases  of  tubercular  leprosy  instanced  by  Kaposi  cannot 
be  considered  proof  that  the  organisms  were  absent,  but  rather  that 
the  methods  employed  were  defective.     On  the  other  hand,  the  absence 


THE  BACrLLUS  LEPE^.  407 

of  the  parasite  in  lepra  nervosa  is  regarded  as  evidence  of  spontaneous 
cure ;  at  least  of  tliat  particular  attack. 

Jlorphclogical  Characters. — The  bacillus  leprae  is  believed  to  belong 
to  the  Streptothrix  family.  It  is  a  near  congener  of  the  bacillus  tuber- 
culosis, and  a  transition  between  the  two  is  found  in  the  bacillus  of 
fowl  tuberculosis.  The  members  of  this  group  are  also  believed  to 
be  allied  to  the  actinomycetes,  which  are  also  pathological. 

The  parasite  is  slender  and  rod-like,  in  length  from  one-half  to 
three-fourths  of  the  diameter  of  a  human  red  blood  corpuscle,  and  in 
breadth  about  one-fifth  of  the  length.  The  ends  are  usually  pointed, 
but  in  certain  cases  are  clubbed,  and  then  resemble  the  Edebs-Loffler 
bacillus.  Dichotomous  division  has  occasionally  been  noted.  Most 
authorities  believe  that  the  bacillus  is  spore-producing  and  also  en- 
capsulated. The  tendency  to  form  colonies  is  a  characteristic  of  this 
parasite.  Young  bacilli  are  homogeneous,  while  the  older  are  gran- 
ular. 

Analogies  icith  Koch's  Bacillus. — The  points  of  agreement  and  dif- 
ference between  the  bacilli  of  leprosy  and  those  of  tuberculosis  are 
of  more  than  passing  interest.  They  show  similar  staining  qualities, 
although  the  lepra  bacilli  stain  with  more  facility,  and  both  occa- 
sionally exhibit  clubbing  of  the  ends  and  dichotomy.  The  lepra 
bacilli  are  more  uniform  in  size  and  rectilinear.  They  may  be  distin- 
guished by  differential  stains,  by  their  greater  number,  and  by  their 
tendency  to  form  colonies. 

The  most  striking  point  of  aflinity,  however,  lies  in  the  similarity 
of  their  toxins.  As  the  bacillus  leprae  cannot  be  cultivated,  we  know  of 
the  leprous  toxins  only  from  their  clinical  results ;  but  the  similarity 
is  shown  by  the  fact  that  lepers  react  both  locally  and  generally  to 
tuberculin — a  fact  of  great  practical  significance  as  holding  out  a  plan 
for  the  rational  treatment  of  the  disease — a  plan  which,  according  to 
Babes,  leads  to  at  least  temporary  improvement  when  vigorously  car- 
ried out  over  long  periods. 

None  of  the  microorganisms  cultivated  from  leprous  tissues  corre- 
sponds to  Hansen's  bacillus,  although  one  of  them,  the  so-called  diph- 
theroid bacillus,  much  resembles  it. 

Methods  of  Examining  for  the  Bacillus  Leprce. 

In  the  Serum. — The  best  method  is  to  clamp  the  nodule  with  a  pair 
of  forceps  or  a  specially  devised  instrument  for  clamping  and  squeez- 
ing the  nodule.  After  the  nodule  becomes  angemic  from  pressure  it 
should  be  freely  incised  at  the  apex,  when  a  small  quantity  of  serum 
will  escape.     The  clear  fluid  which  exudes  is  to  be  placed  upon  a  clean 


408  MOKROW — LEPEOSY. 

cover  glass,  and  if  this  is  brought  in  contact  with  a  second  cover  glass 
a  thin  film  of  exudation  will  spread  evenly  between  the  two,  when 
they  are  to  be  carefully  separated.  The  cover  glasses  are  now  passed 
through  the  flame  of  a  spirit  lamp,  which  fixes  the  film  and  assists  in 
the  process  of  staining. 

The  preparation  is  now  to  be  stained  in  an  aqueous  solution  of 
fuchsin,  or  better,  a  three-per-cent.  solution  of  carbolic  acid  should 
be  added  to  the  fuchsin,  which  assists  the  staining-process.  If  now 
the  specimen  be  decolorized  in  a  thirty-per-cent.  solution  of  nitric 
acid  and  counterstained  with  a  methylene-blue  solution,  washed  in 
water,  dried,  and  mounted  in  xylol-Canada  balsam,  it  will  show  the 
bacilli  single  and  in  clusters  stained  red,  while  the  nuclei  and  ground 
substance  are  stained  blue. 

In  the  Tissues. — After  the  section  is  properly  cut  with  a  microtome 
it  should  be  placed  in  a  fuchsin-carbol  solution  for  some  hours.  It 
should  be  removed  carefulh'  and  dipped  in  a  thirty-per-cent.  solution 
of  hydrochloric  or  nitric  acid.  This  will  decolorize  everything  excei)t 
the  bacilli.  If  the  section  is  now  stained  with  methylene  blue,  the 
red-stained  bacilli  will  appear  under  the  microscope  as  pink  rods 
upon  a  blue  ground. 

Alvarez,  of  Honolulu,  has  proposed  a  rapid  method  of  making  a 
positive  diagnosis  in  doubtful  cases.  After  the  removal  of  a  bit  of 
skin  or  other  tissue  to  be  examined  it  is  washed  in  a  normal  salt  solu- 
tion and  thoroughly  triturated  in  a  small  mortar  until  a  homogeneous 
solution  results.  The  skin  or  other  tissue  may  be  boiled,  or  digestive 
ferments  may  be  added,  before  it  is  submitted  to  the  process  of  tritu- 
ration. When  the  trituration  is  completed,  a  small  quantity  may  be 
transferred  to  a  cover-glass,  and  the  specimen  is  then  fixed,  stained, 
decolorized,  and  counterstained  in  the  manner  described  above.  If 
there  are  but  few  bacilli  present,  the  triturated  mass  may  be  sub- 
mitted to  a  centrifugal  machine  or  placed  in  a  conical  glass,  and  the 
sediment  examined  in  twenty-four  or  forty-eight  hours. 

Alvarez  claims  that  by  this  method  we  can  spread  upon  the  cover- 
glass  films  thinner  than  any  section  that  can  be  made  with  a  micro- 
tome, and  by  using  the  centrifugal  machine  we  can  gather  bacilli  in  a 
small  place,  where  they  are  easier  to  find  than  in  a  section.  More- 
over, a  diagnosis  can  be  made  in  a  few  minutes  instead  of  waiting  for 
the  tissues  to  harden. 

Culture  Uxpei'iments. 

Experiments  in  the  artificial  cultivation  of  lepra  bacilli  in  various 
culture  mediums  have  uniformly  failed.  The  authenticity  of  cultures 
claimed  to  be  successful  by  numerous  investigators  have  all  been  con- 


THE  BACILLUS  LEPK^.  409 

tested,  since  iu  no  instance  lias  the  x^athogenic  nature  of  tliese  cul- 
tivations been  established  by  inoculation  experiments. 

Possibly  au  explanation  of  the  uniform  failure  of  all  culture  exper- 
iments is  that  due  regard  has  not  been  paid  to  the  element  of  time, 
which  is  so  essential  a  condition  of  the  germinative  capacity  of  the 
lepra  bacillus,  and  results  may  have  been  looked  for  too  early. 

Quite  recently  Carrasquilla,  known  as  the  originator  of  the  serum 
therapy  of  leprosy,  claims  to  have  made  successful  cultures  of  the 
bacillus  leprse.  His  method  of  procedure  and  results  are  de- 
scribed in  a  communication  to  the  National  Academy  of  Medicine 
of  Bogota,  February,  1899.  He  collects  the  serum  by  means  of  a 
specialh'  devised  clamp  or  forceps  applied  to  the  tubercles,  macules, 
or  infiltrations.  The  clear  fluid  collected  is  first  examined  under  the 
microscope  to  be  sure  that  it  contains  Hansen's  bacillus.  Tubes  of 
gelatinized  serum  are  then  sown  with  a  drop  of  the  cle^r  fluid  on  a 
sterilized  platinum  wire  and  placed  in  a  Eoux  condenser  at  a  tem- 
perature of  37'  C. 

At  the  end  of  twenty-four  hours  he  saw  the  development  of  the 
first  culture.  Spots  or  macules  had  appeared  all  around  the  points 
sown  with  the  platinum  wire,  with  rounded,  irregular  contours,  some 
yellow,  others  white  with  a  certain  refraction.  Four  days  later  he 
examined  under  the  microscope  the  colonies  of  the  first  tubes  sown 
and  was  able  to  demonstrate  the  presence  of  the  bacilli,  even  with- 
out coloration.  Submitted  to  the  ordinary  coloring  methods,  all 
the  characteristics  of  Hansen's  bacillus  were  displayed,  while  no 
other  microbe  aj)peared  in  the  preparation,  showing  that  it  was 
a  pure  culture.  Taking  this  first  culture,  he  sowed  other  tubes  of 
gelatinized  serum,  and  these  produced  exactlj^  the  same  develop- 
ment as  the  first,  which  were  sown  directly  from  the  lej^rous  exuda- 
tion. Later  he  used  as  a  culture  fluid  the  bouillon  of  beef  with 
identical  results.  One  set  of  tubes  was  sown  with  the  culture  of  pre- 
ceding tubes,  and  the  same  series  of  phenomena  was  always  produced 
under  identical  conditions.  A  month  later,  in  examining  the  cul- 
tures, he  was  surprised  to  see  the  bacilli  in  movement,  and  in  exam- 
ining cultures  there  was  always  observed  a  mobility  of  the  bacilli 
after  a  certain  stage  of  their  development.  He  was  also  enabled  to 
identify  different  phases  in  the  evolution  of  the  microbes  as  shown  by 
differences  in  their  morphological  characters  and  movements. 

Carrasquilla  further  claims  that,  when  injected  into  horses,  the 
filtered  liquid  of  the  cultures  produced  precisely  the  same  effect,  al- 
though the  reaction  was  more  intense,  as  the  serum  taken  directly  from 
lepers.  Furthermore,  the  serum  of  the  horses  which  had  received  in- 
oculations of  the  liquid  from  the  cultures  produced  in  patients  the 


410  MORROW— LEPROSY. 

same  reactions  and  the  same  modifications  in  the  manifestations  of 
the  disease,  only  perhaps  more  pronounced,  as  the  serum  from  horses 
which  had  been  inoculated  with  the  serum  of  lepers. 

Carrasquilla  does  not  believe  that  the  immunity  of  animals  to 
leprosy  is  so  absolute  as  has  been  maintained,  and  since  experiments 
in  inoculating  human  beings  are  not  permissible,  his  further  experi- 
ments are  to  be  conducted  with  a  view  of  reproducing  the  disease  in 
animals  by  means  of  his  cultures. 

Until  this  final  proof  of  the  i)athogenic  action  of  the  cultures  is 
furnished  Carrasciuilla's  claims  must  be  received  with  the  same  scep- 
ticism as  has  been  accorded  b\'  the  i)rofession  to  those  of  Bordoni- 
Uffreduzzi  of  Turin,  Spronck  of  Utrecht,  Byron  of  New  York,  and 
others,  who  have  announced  successful  results  in  cultivating  the  lepra 
bacillus. 

I)  isi  rib  id  ion,  of  the  Bacilli. 

Leprosy,  according  to  Cornil,  is  the  perfected  type  of  bacterial 
disease.  By  the  extreme  abundance  of  bacilli  infiltrated  everywhere 
in  the  i^athological  products  of  leprosy,  by  their  persistence  at  all 
periods,  this  disease  gives  us  the  most  characteristic  histological  dem- 
onstration of  the  role  of  the  bacillus.  No  other  disease  is  so  rich  in 
bacilli.     All  leprous  products  contain  colossal  quantities  of  bacilli. 

Like  all  specific  microbes,  the  lepra  bacillus  has  an  elective  aflinity 
or  predilection  for  certain  tissues  and  fluids  of  the  bodj-.  The  bacilli 
are  present  in  all  forms  and  stages  of  tubercular  leprosy ;  they  are 
found  in  both  the  diffuse  and  nodular  infiltrations  of  the  skin  and 
mucous  membranes,  in  the  connective  tissue  of  the  peripheral  nerves, 
in  the  spinal  cord  (the  anterior  horns)  and  in  the  spinal  ganglia,  in  the 
cornea,  the  cartilages,  and  the  liver,  spleen,  and  kidneys,  si)aringly 
in  the  spermatic  tubes  and  testicles,  also  in  the  ovary  and  the  lemale 
breasts.  They  are  found  abundantly  in  the  lymphatic  glands  and 
spaces,  in  the  sebaceous  glands,  and  in  the  hair  and  sebaceous  follicles 
of  the  body,  but  not  of  the  scalp.  The}'  are  not  found  in  the  blood, 
except  in  the  last  stages  of  the  disease.  It  is  claimed  that  they 
exist  in  the  blood  during  the  febrile  or  congestive  attacks,  but  this 
has  not  been  determined.  The  blood  would  seem  to  serve  as  an 
agent  of  transport  for  the  dissemination  of  the  bacilli  through  the 
economy.  The  bacilli  exist  in  a  state  of  permanence  in  the  lymph, 
and  this  fluid  is  regarded  as  the  natural  culture  fluid  of  the  microbes. 

Their  in-esence  in  the  pi/  t/siolog iced  secretions,  the  tears,  saliva,  milk, 
and  semen,  though  formerly  denied,  is  now  attested  by  Babes ;  they 
have  never  been  found  in  the  urine,  nor  in  the  menstrual  fluid.  It  is 
probable    that  the   jjhysiological   secretions,  unless    pathologically 


THE  BACILLrS  LEPE^.  411 

altered  bv  the  presence  of  leprous  deposits  in  the  secretory  structures 
of  the  organs,  do  not  contain  leprous  microorganisms.  The  bacilli 
are,  however,  also  found  upon  the  skin  and  in  organs  which  are  to  all 
appearances  perfectly  healthy. 

The  'pathological  secretions  from  the  surface  of  ulcerating  lesions 
of  the  integuments,  of  those  of  the  mucous  membranes  of  the  nose, 
mouth,  and  throat,  the  large  intestine,  and  the  rectum  contain  large 
numbers  of  the  bacilli,  which  are  discharged  through  the  nasal  mu- 
cus, the  saliya,  and  dysenteroid  excrement  in  vast  quantity. 

It  is  to  be  observed  that  individual  cases  may  present  the  greatest 
variations  in  respect  to  the  lesions  and  secretions  which  contain 
bacilli.  Thus  Weber  found  that  bacilli  were  in  one  case  present  in 
skin  scrapings,  lanugo  hairs,  blood  from  nodules,  serum  from  vesi- 
cles, semen,  etc.,  and  entirely  absent  in  the  saliva,  nasal  mucus,  scalp 
hairs,  and  in  blood  not  taken  from  nodules. 

The  special  reactions  between  the  bacillus  and  iudividual  tissues 
are  best  treated  of  under  particular  headings.  With  regard  to  the 
migration  of  the  parasite  within  the  body  and  the  problem  of  its 
preference  for  individual  tissues,  we  are  still  in  great  obscurity. 

EUminatioii  of  tlie  Bacilli. 

The  bacilli  leave  the  body  by  means  of  every  natural  secretion  or 
excretion,  with  the  i^ossible  exception  of  the  urine — in  saliva,  nasal 
mucus,  conjunctival  secretion,  vaginal,  urethral,  and  uterine  dis- 
charges, semen,  milk,  faeces,  secretion  of  leprous  ulcers,  and  the  free 
surface  of  the  skin.  They  have  not  been  found  in  the  menstrual  blood 
(Babes). 

The  nodules  and  diffused  infiltrations  of  the  skin  and  of  the  mucosa 
of  the  nose,  mouth,  and  throat,  the  large  intestine,  and  the  rectum 
contain  immense  numbers  of  bacilli  which  are  set  free  on  the  break- 
ing down  of  these  tissues.  Once  freed  from  their  nidus,  their  dissemi- 
nation is  a  matter  of  chance. 

Schaffer  claims  that  lepers  throw  off  fewer  bacilli  from  the  skin 
than  from  the  buccal  and  nasal  mucosa  in  coughing  and  sneezing. 
He  was  able  to  collect  lepra  baciUi  on  clean  slides  placed  on  tables 
and  the  floor  near  to  patients  whom  he  had  caused  to  read  aloud. 
Lepers  who  had  been  reading  aloud  only  ten  minutes  projected  from 
forty  to  one  hundred  and  eighty-five  thousand  bacilli. 


412  MORROW — LEPROSY. 


The  BacilH  Outside  the  Body. 

Bacilli  have  beeu  found  in  the  habitations  of  lepers,  articles  of 
furniture,  and  objects  surrounding^  the  leper.  They  have  also  been 
found  sparingly  in  the  dust  and  dirt  of  rooms  where  lepers  have  lived, 
iu  the  soil  habitually  trodden  by  lepers'  feet,  and  in  the  earth  where 
lepers  have  been  buried. 

From  the  fact  that  the  leper  discharges  from  his  skin  and  nasal  and 
buccal  mucous  membranes,  and  with  his  breath  iu  talking,  coughing, 
sneezing,  etc.,  myriads  of  bacilli,  and  that  these  bacilli  must  of  neces- 
sity come  in  contact  with  a  large  entourage  of  healthy  people,  none 
of  whom  may  be  contaminated,  it  is  evident  that  these  bacteria  are 
either  endowed  with  a  very  feeble  contagious  activity,  or  that  they  are 
dead  or  cadaveric  when  discharged.  This  cadaverization  of  the  bacil- 
lus explains,  according  to  Besnier,  the  negative  results  of  cultures  and 
inoculations  and  enables  us  to  understand  why  it  is  that  leprosy  is 
wiped  out  when  the  leper  dies,  offering  a  new  and  fundamental  dis- 
tinction from  Koch's  bacillus  which  retains  its  vitality  and  virulence 
through  an  incredible  length  of  time  and  under  various  conditions. 
The  question  whether  the  bacilli  found  outside  the  body  are  living 
or  dead  is  still  ^nh  judice,  and  cannot  be  decided  either  affirmatively 
or  negatively  until  we  are  able  to  show  some  comprehensible  differ- 
ence between  living  and  dead  bacilli  by  culture  or  inoculation. 

Arning  states  that  the  bacilli  seem  to  multiply  in  the  bodies  of  dead 
lepers  months  after  they  have  been  buried.  He  has  also  obser\'ed 
that  fragments  of  lepromata  i:)laced  in  water  for  several  months  became 
surrounded  w'ith  myriads  of  bacilli,  ver}^  evidently  multiplied,  and 
which  proves  to  him  that  ihej  are  living. 

Babes  also  concludes  from  certain  characters  of  the  bacilli,  the 
globi  and  the  api^earances  of  sporulation,  that  some  of  them,  at  least, 
are  living. 

Transmission  of  the  Bacilli. 

As  the  bacillus  leprae  has  not  been  cultivated  we  have  no  certain 
means  of  determining  to  what  extent  the  bacilli  which  infest  the 
numerous  secretions  and  discharges  are  lifeless,  and  for  the  same 
reason  we  have  no  positive  evidence  as  to  how  the  disease  is  spread. 

Since  the  bacilli  are  present  in  the  semen  at  an  earlj^  period  of 
the  disease,  although  a  condition  of  azoospermia  soon  supervenes,  and 
the  milk  of  women  with  tubercular  leprosy  also  contains  the  parasite, 
Babes  believes  we  are  warranted  in  the  assumption  that  bacilli  may 
pass  between  two  individuals  in  the  processes  of  generation  and  lac- 


THE  BACILLUS  LEPE^.  413 

tation.  This  would  not,  however,  necessarily  indicate  that  the  dis- 
ease was  inherited.  The  ovary  also  contains  bacilli,  but  much  less 
frequently  and  to  a  less  extent  than  the  testicle. 

Of  other  modes  of  transmission,  direct  and  indirect,  Babes  thinks 
that  the  aerial  route  from  the  germ-impregnated  dust  to  the  pores  of 
the  face,  especially  when  the  pores  are  large  and  the  subject  unclean- 
ly, has  the  most  to  recommend  it.  The  reasoning  to  establish  this 
belief  is  not  a  priori,  but  is  based  upon  the  peculiar  small  perifollicu- 
lar foci  of  infiltration  which  are  so  characteristic  of  tubercular  leprosy 
of  the  skin.  Under  the  microscoj^e  this  iDhenomenon  is  suggestive  of 
the  possibility  of  the  penetration  of  the  bacilli  through  the  follicular 
wall  from  without.  The  converse,  namely,  the  penetration  of  the 
follicular  wall  from  within  outwards  in  advanced  cases  of  tubercular 
leprosy,  is  well  authenticated,  and  by  this  means  the  bacilli,  which 
appear  to  be  unable  to  make  their  way  through  the  epidermis,  suc- 
ceed in  reaching  the  free  surface  of  the  skin  when  the  latter  is  still 
unbroken. 

Babes  himself  warns  against  too  hastily  adopting  this  view.  We 
only  know  that  the  hair  follicle  is  a  predilection  locality  in  leprosy, 
and  under  these  circumstances  the  parasite  may  be  able  to  reach  it, 
no  matter  how  it  has  entered  the  body. 

With  regard  to  other  i:)ossible  modes  of  transmission,  we  have  no 
guide  but  the  analogy  of  other  diseases.  In  addition  to  the  lodging 
of  germ-laden  dust  in  large  pores  and  abrasions,  the  bacilli  may  find 
ports  of  entry  through  the  mucous  membranes  of  the  nose,  tonsils, 
conjunctiva,  the  deeper  air  and  food  passages,  and  perhaps  the  geni- 
tals, since  primary  lepromata  are  occasionally  seen  in  the  latter  local- 
ity. When  we  come  to  lepra  nervosa,  the  question  of  transmission 
becomes  even  more  obscure. 

In  connection  with  this  whole  question  it  is  well  to  remember  that 
thus  far  there  is  absolutely  no  certain  evidence  of  the  disease  being 
conveyed  by  inoculation. 

Resistance  of  the  Bacilli. 

The  resistance  of  the  bacilli  to  disintegration  and  decay  -is  most 
remarkable.  Thousands  of  bacilli  have  been  found  in  a  small  frag- 
ment of  a  leprous  nodule  which  had  become  dried  in  an  envelope  of 
paper,  where  it  had  been  forgotten  for  ten  years.  Bacilli  may  re- 
main almost  indefinitely  in  tissues  where  they  are  developed,  show- 
ing no  tendency  to  be  eliminated  or  destroyed  ultimately  (Cornil  and 
Babes) .  When  introduced  experimentally,  bacilli  have  been  found  in 
fragments  of  nodules  which  had  been  inserted  under  the  skin  of 
animals  one  to  two  years  previously. 


414  MORROW — LEPROSY. 

"NVeseuer's  experiments  would  go  to  show  that,  unlike  the  bacilli 
of  tuberculosis,  lepra  bacilli,  if  introduced  in  the  living  tissues,  re- 
main unabsorbed  and  susceptible  of  being  impregnated  by  coloring 
matter  for  an  indefinite  length  of  time.  He  found  the  results  to  be 
identically  the  same,  whether  he  introduced  pieces  containing  bacilli 
which  had  sojourned  in  alcohol  for  two  years  or  fresh  pieces.  In 
both  cases  the  only  manifest  reaction  was  of  a  phlogistic  nature,  of  a 
purely  local  character,  and  similar  to  that  which  would  have  followed 
the  introduction  of  any  inanimate  matter,  such  as  charcoal  or  cinna- 
bar. The  bacilli  become  incorporated  with  the  cellular  elements,  and 
their  form  persists  intact. 

Variations  in  the  Bacilli. 

Variations  in  Sfaininr/  Qualities. — In  a  communication  to  the  Ber- 
lin Leprosy  Congress,  1897,  on  "The  Bacillus  of  Leprosy  in  the 
Human  System  at  Different  Periods  of  its  Growth,"  Lawrence  Her- 
man has  demonstrated  that  these  variations  are  especially  manifest  in 
relation  to  the  staining  reactions  of  the  bacilli.  He  found  in  a  mass 
of  bacilli  which  he  extracted  from  tubercles  and  in  sections  that  the 
bacilli  did  not  all  color  in  the  same  manner.  The  bacilli  from  recent 
nodiiles  retained  less  carbol-fuchsin  and  took  on  a  secondary  colora- 
tion of  methylene  blue.  In  preparations  from  older  nodules  there 
are  seen  in  the  blue-stained  masses,  now  and  then,  bacilli  which  have 
retained  the  fuchsin  and  are  stained  red.  He  has  encountered:  1. 
Eed-stained  bacilli  which  have  remained  well  stained  deep  red;  2. 
pale  red-stained  bacilli  which  have  become  decolorized  to  a  greater 
or  less  extent;  3.  bacilli  which  have  lost  their  fuchsin  and  become 
stained  more  or  less  blue. 

Herman  concludes  from  his  investigations  that  the  bacilli  which 
are  easily  decolorized  and  have  by  contrast  taken  the  methylene-blue 
stain  are  the  more  recent  and  active  bacilli,  while  those  which  have  re- 
tained the  red  stain  and  are  more  resistant  to  the  decolorizing  effect  of 
nitric  acid  rejiresent  the  older,  possibly  more  stationary  forms. 

Further  researches  are  necessary  before  it  can  be  determined 
whether  the  tinctorial  differences  between  bacilli  of  different  ages 
indicate  a  modification  in  their  infective  virulence. 

Variations  in  Virulence. — A  priori  it  might  be  assumed  that  specific 
bacilli  possess  the  same  character  and  degree  of  virulence  irrespective 
of  the  source  from  which  they  are  derived.  Experiment  has  shown, 
however,  that  cultures  of  tubercle  bacilli  from  bone  tuberculosis  are 
more  highly  virulent  than  cultures  of  sputum  bacilli,  and  it  is  also 
claimed  that  different  varieties  of  human  tuberculosis  exhibit  marked 
differences  in  their  respective  virulence. 


THE  BACILLUS  LEPE^.  415 

Since  successful  cultures  of  the  lepvsb  bacilli  have  never  been 
made,  the  determination  of  their  comparative  virulence  must  be  based 
upon  clinical  evidence  alone.  Observation  would  seem  to  show  con- 
clusively that  differences  in  the  virulence  of  lej^rous  germs  are  mani- 
fest not  only  in  respect  to  their  contagious  activity,  but  also  in  re- 
spect to  the  intensity  and  severity  of  their  pathogenic  action  when 
introduced  into  the  body.  It  is  well  known  that  leprosy  is  feebly 
contagious  in  certain  countries  and  ultracontagious  in  others,  while 
the  virulence  of  the  morbid  process  in  the  tubercular  form  contrasts 
with  its  comparative  benignity  in  the  ansesthetic  form. 

The  causes  of  the  great  diversity  in  the  objective  characters  and 
course  of  the  two  principal  forms  of  leprosy,  the  rapid  multiplication 
of  the  bacilli  and  their  predilection  for  the  cutaneous  tissues  in  the 
one  form,  their  comparative  fewness  and  preference  for  the  nerve 
structures  in  the  other,  has  been  variously  interpreted.  It  was  a 
subject  of  inquiry  by  the  recent  Berlin  Leprosy  Congress,  and  by  cer- 
tain leprologists  the  difference  was  attributed  to  the  variable  viru- 
lence of  the  bacilli. 

Hansen  considers  it  a  begging  of  the  question  to  invoke  a  variable 
virulence  of  the  bacillus  or  a  predisposition  and  a  relative  immunity 
of  the  soil;  he  thinks  that  climate  influences  the  form. 

Blaschko  thinks  there  is  no  essential  difference  between  the  two 
forms,  but  only  a  difference  in  the  quantity  of  the  bacilli. 

Arning,  on  the  contrary,  regards  the  difference  as  fundamental  and 
believes  that  the  bacilli  have  a  different  action  in  the  two  forms. 

According  to  Neisser,  it  is  not  a  simple  difference  in  the  quantity 
of  the  bacilli,  but  a  qualitative  difference  in  the  morbid  process, 
besides  a  different  localization,  it  being  in  the  cutaneous  form  prolif- 
erative and  in  the  nerve  form  atrophic  and  retractive. 

Impey  thinks  that  there  are  either  two  very  similar  but  not  identi- 
cal bacilli  in  leprosy,  or  that  in  pure  nerve  leprosy  the  poison  secreted 
by  the  bacilli  acts  in  a  more  powerful  manner  upon  the  nerves,  because 
the  nervous  system  of  the  patient  is  peculiarly  susceptible  to  the  ef- 
fects of  the  ptomain. 

In  the  writer's  opinion  the  explanation  of  the  difference  in  the  two 
forms  must  be  sought  for,  not  in  a  difference  in  the  virulence  of  the 
germs,  but  in  the  character  of  the  soil.  The  type  or  form  of  the  mor- 
bid process  is  determined  by  the  idiosyncrasy  of  the  individual  or  by 
some  pathological  predisposition  which  in  the  one  case  renders  the 
skin,  in  the  other  the  nerves,  more  susceptible  to  the  pathogenic 
action  of  the  bacilli.  As  regards  the  infective  virulence  of  the  bacilli, 
it  is  claimed  that  the  tubercular  form  is  highly  contagious,  while  the 
other  is  comparatively  innocuous.     This  may  result  not  from  a  differ- 


416  MORROW— LEPROSY. 

ence  in  the  virulence  of  the  germs,  but  simph'  from  the  accident  of 
their  localization,  which  in  the  one  form  permits  of  their  abundant 
and  ready  discharge,  while  in  the  other  they  are  chiefly  confined  in 
the  nerve  structures. 

At  the  same  time  there  can  be  but  little  doubt  that  the  infective 
virulence  of  leprous  germs  is  modified  by  climate  and  conditions  of 
environment  which  render  the  system  sterile  or  antagonistic  to  their 
development. 

Inoculation  in  Man. 

Before  the  bacillary  origin  of  leprosy  was  demonstrated  and  dur- 
ing the  i:)eriod  when  the  theory  of  the  non-contagiousness  of  leprosy 
was  in  the  ascendency,  numerous  attempts  were  made  to  inoculate 
human  beings.  At  the  present  day  it  would  be  difficult  to  find  any 
one  who  would  dare  attempt  to  inoculate  leprosy. 

In  1844  Dauiellsen,  who  was  a  firm  believer  in  the  non-contagious- 
ness of  leprosy,  first  inoculated  himself  with  portions  of  a  tubercle 
from  a  leprous  patient.  He  repeated  this  experiment  on  himself  later 
in  the  same  jear  without  other  result  than  the  production  of  a  septic 
lymi)hangitis.  Still  later,  he  inoculated  two  helpers  and  one  nurse  in 
St.  George's  Hospital  in  Bergen,  all  with  negative  results.  In  1846 
he  inserted  a  small  leprous  nodule  under  the  skin  of  his  left  forearm 
and  the  wound  was  sutured.  The  sutures  cut  through,  and  after  a 
few  days  an  ulcer  formed  which  healed  in  a  few  weeks. 

In  1856  Daniellsen,  his  assistant,  Loberg,  a  farmer,  two  waiters, 
and  a  servant  at  Lungegaard's  Hospital  were  inoculated  with  por- 
tions of  tubercles,  blood,  and  the  pleural  exudation  from  a  leper. 
In  1857  several  syphilitic  and  favus  patients  were  inoculated,  and  in 
1858  Daniellsen  and  a  waiter  were  again  inoculated,  with  negative  re- 
sults. The  inoculations  were  ordinarily  made  in  the  arm,  and  when 
the  leprous  products  were  inserted  the  wound  was  sutured  and  covered 
with  plaster.  There  were  ordinarily  redness  and  swelling  over  the 
sutures  and  after  about  fourteen  days  the  individuals  were  all  right. 

Altogether  Daniellsen  inoculated  twenty  healthy  individuals  with 
the  blood  of  lepers,  portions  of  tubercles,  and  blood  collected  from 
the  surfaces  of  the  tubercles.  There  were  observed  a  few  cases  of 
lymphangitis,  but  in  none  of  the  twenty  cases  did  he  produce  a 
condition  resembling  leprosy.  Some  of  these  patients  were  kept 
under  observation  many  years,  but  all  remained  perfectly  healthy. 
The  negative  results  of  these  experiments  contributed  largeh'  to  con- 
firm the  opinion  that  leprosy  was  neither  contagious  nor  inociilable. 

Profeta,  between  1868  and  1875,  inoculated  himself,  Cagnina,  six 
men,  and  two  women,  all  with  their  free  consent,  but  the  results 


THE   BACILLUS   LEPE^.  417 

were  negative.  Bargilli  of  Mytelene  made  two  unsuccessful  inocu- 
lations. 

Hansen  inoculated  the  products  of  tubercular  leprosy  in  persons 
already  suffering  from  aneestlietic  leprosy  without  result.  Both  Han- 
sen and  Beaven  Bake  also  found  that  the  local  lesions  of  leprosy  were 
not  produced  when  the  diseased  tissues  from  a  leper  were  inserted  in 
a  healthy  part  of  the  same  person,  which  would  seem  to  indicate  that 
the  bacillus  does  not  grow  in  healthy  tissues  of  the  leper,  but  only  in 
a  part  made  suitable  for  its  reception  and  growth  by  a  process  of 
preparation  not  yet  determined. 

In  addition  to  these  experimental  inoculations,  which  were  under- 
taken with  a  definite  scientific  object  in  view,  may  be  added  accidental 
inoculations,  in  cases  of  physicians  or  nurses  who  have  pricked  or 
wounded  themselves  in  dressing  the  open  sores  of  lepers  and  in  per- 
forming operations  or  autopsies.  In  none  of  these  cases  has  leprosy 
developed. 

Reference  may  also  be  made  to  cases  in  which  leprosy  is  said  to 
have  been  contracted  by  thrusting  a  needle  or  knife  which  had  pre- 
^iously  been  passed  into  the  tissues  of  a  leper  into  the  tissues  of 
healthy  individuals  in  a  spirit  of  bravado,  as  in  Hildebrand's  case, 
and  to  Blanc's  case  of  leprosy  following  a  razor  cut  in  an  English 
nurse,  etc.  These  cases  are  open  to  the  possibility  of  doubt  as  to 
whether  the  disease  was  inoculated  in  the  manner  alleged,  as  the  pa- 
tients were  in  more  or  less  constant  intercourse  with  lepers,  afford- 
ing abundant  opportunities  for  infection  in  other  ways. 

The  only  experiment  claimed  to  be  successful  in  inoculating 
leprosj^  in  man  was  that  of  the  convict  Keanu  of  Hawaii,  who  was 
inoculated  by  Arning  in  1884  with  pus  laden  with  bacilli,  and,  in  addi- 
tion, a  portion  of  a  tubercular  nodule  was  inserted  subcutaneously. 
This  man  developed  leprosy  from  which  he  has  since  died.  In  1889, 
on  a  visit  to  the  leper  settlement  of  Molakai  where  Keanu  had  been 
sent,  I  excised  a  small  cutaneous  nodule  from  his  arm  with  a  portion 
of  the  overlying  skin.  Bacilli  were  found  abundanth'  in  numerous 
specimens  of  this  section.  The  scientific  value  of  Arning's  experi- 
ment has  been  nullified  by  the  fact  that  Keanu  came  of  a  leprous 
family,  and  it  is  not  at  all  improbable  that  he  had  the  seeds  of  the 
disease  in  his  system  previous  to  the  experimental  inoculation. 

Inoculation  in  Animals. 

All  attempts  to  inoculate  animals  with  the  products  of  leprosy 
have  been  uniformly  unsuccessful.     Almost  every  species  of  animal 
life  has  been  subject  to  experimental  inoculations.     Hansen  endeav- 
VoL.  XVIII. —27 


418  MORROW— LEPROSY. 

ored  to  inoculate  cats,  rabbits,  and  monkeys.  Kobner  inoculated 
monkeys,  frogs,  and  various  species  of  fisli.  Hillairet  and  Gaudier 
inoculated  swine,  but  without  results.  Neisser,  in  inoculating  dogs 
and  rabbits,  and  Damscli,  in  inoculating  mice  and  cats,  have  produced 
local  manifestations  of  the  disease  in  the  tissues  surrounding  the 
nodule  of  inoculation. 

Leloir  inoculated  five  rabbits  with  i)ieces  of  tubercular  nodules, 
introduced  under  the  skin  and  into  the  jjeritoneal  cavity.  In  one 
case,  after  six  months  bacilli  were  found  in  the  nodules,  but  none  in 
the  surrounding  tissues.  In  another  case  he  found  bacilli  in  the  tis- 
sues, but  regarded  them  as  bacilli  coming  from  the  nodule  of  inocula- 
tion, and  not  as  new  bacilli  which  had  been  produced  by  the  process 
of  growth  and  multiplication. 

Beaveu  Eake  inoculated  cats,  introducing  the  lei)rous  material 
under  the  skin,  in  the  peritoneal  cavity,  and  in  the  anterior  chamber  of 
the  eye.  These  he  kept  under  observation  for  four  or  five  years,  but 
without  finding  an}'  local  growth  or  general  dissemination  of  the  ba- 
cilli. Hansen  inoculated  animals  with  what  he  presumed  to  be  pure 
cultures  of  the  bacilli  with  negative  results.  Melcher  and  Ortmann 
reported  that  they  succeeded  in  inoculating  a  rabbit  by  the  insertion 
of  a  i)ortion  of  a  lej^rous  tubercle  in  the  anterior  chamber  of  the  eye. 
The  animal  remained  apparently  health^',  but  suddenly  died  several 
months  later.  The  lungs,  heart,  and  pericardium  were  found  to  be 
the  seat  of  an  ai)parently  fresh  tubercular  eruption.  In  the  afi'ected 
parts  large  round  and  oval  cells  were  found  containing  bacilli  which 
the  authors  regard  as  lepra  bacilli  and  not  tubercle  bacilli.  Later 
they  reported  that  they  had  succeeded  in  inoculating  two  rabbits 
which  died  four  months  after  inoculation.  The  whole  of  the  vis- 
cera was  the  seat  of  a  nodular  eruption  which  they  regarded  as 
leprous.  The  similarity  of  the  tuberccle  and  lepra  bacilli  and  the 
difliculty  of  differentiating  the  nodules  of  tuberculosis  from  the  nodules 
of  leprosy  must  be  considered  in  appreciating  the  value  of  these  experi- 
ments.    Feeding  with  leprous  tissue  has  also  failed  to  give  results. 

Dr.  J.  F.  Dixon,  medical  superintendent  of  Robbeu  Island, 
Cape  of  Good  Hojie,  has  contributed  some  curious  facts  illustrating 
the  immunity  of  animals  to  leprous  infection.  He  says  (Journal 
Leprosy  Investigaihuj  Committee)  "the  domesticated  animals  of  Eob- 
ben  Island  have  furnished  additional  evidence  on  the  question  under 
consideration  for  many  years  past  and  may  be  almost  sjDoken  of  as 
having  conducted  an  unsolicited  series  of  exi^eriments  on  their  own 
persons  which  are  of  grave  significance  in  this  inquiry. 

"Until  quite  recently  the  cows,  and  more  especially  the  calves, 
were  in  the  habit  of  consuming  large  quantities  of  poultice  recently 


SOUECES   OF  INFECTION.  419 

taken  from  leprous  ulcers  and  thrown  out  into  the  compound,  and 
rags  and  cloths  that  had  been  used  in  binding  up  leprous  sores. 
The  poultry  also  used  to  eat  discarded  food  and  refuse  thrown  from 
the  leper  wards. 

"  The  water  in  which  the  soiled  and  filthy  clothes  and  rags  of  the 
lepers  had  been  washed  (in  cold  water  only)  was  allowed  to  run  down 
an  open  gutter  of  considerable  length  and  was  drunk  regularly  by 
the  cows,  calves,  and  i^oultrj^  of  all  kinds. 

"  This  had  been  going  on  for  many  years,  and  all  the  time  the  flesh 
of  the  animals  and  poultry,  the  hens'  eggs,  and  the  milk  of  the  cows 
had  been  freely  and  constantly  used  by  all  sections  of  the  inhabitants, 
who  nevertheless  remained  healthy.  The  general  health  of  the  cattle 
and  poultry  on  the  island  is  excellent,  and  the  conclusion  seems 
inevitable  that  leprosy  is  not  transferable  through  the  medium  of  the 
lower  animals." 

Sources  of  Infection. 

Recognizing  Hansen's  bacillus  as  the  active  efficient  cause  of 
leprosy,  it  may  be  assumed  that  all  of  the  tissues  of  the  body  of  the 
leper  containing  this  organism  constitute  possible  sources  of  infec- 
tion; the  conditions  of  infection  being  that  the  bacilli  should  be  dis- 
charged from  the  bod}'  of  the  leper,  brought  in  contact  with  and  be 
capable  of  penetrating  the  tissues  of  a  healthy  organism  in  an  oppor- 
tune place  favorable  for  its  germination. 

It  is  evident  that  the  more  numerous  the  bacilli  and  the  greater 
the  facility  of  their  discharge  from  the  body  of  the  leper,  the  more 
active  and  virulent  the  source  of  contagion.  The  tubercular  leper, 
whose  cutaneous  tissues  swarm  with  the  bacilli  and  which  are  given 
off  in  myriads  from  the  open  surface  of  the  broken-down  tubercles,  has 
undoubtedly  a  greater  contagious  activity  than  the  ansesthetic  leper  in 
whom  the  bacilli  are  comjDaratively  few  and  embedded  deeply  in  the 
nerves  from  which  they  cannot  readily  find  egress.  It  was  formerly 
believed  that  the  tubercular  ulcerations  from  which  the  bacilli  are 
discharged  in  myriads  aft'orded  the  most  prolific  as  well  as  the  princi- 
pal sources  of  infection.  This  view  would  imply  a  limitation  of  the 
danger  to  the  i^eriod  of  ulceration,  also  that  the  anaesthetic  leper  is 
feebly  or  not  at  all  contagious. 

Eecent  bacteriological  investigations,  especially  of  leprous  lesions 
of  the  mucous  membranes,  would  seem  to  indicate  the  existence  in 
these  structures  of  possible  sources  of  leprous  contagion,  the  impor- 
tance of  which  has  been  entirely  overlooked  or  at  least  not  sufficiently 
appreciated.  The  investigations  of  G.  Sticker  and  of  Jeanselme  and 
Laurens  on  leprous  lesions  of  the  mucous  membranes  of  the  nose. 


420  MORROW— LEPROSY. 

mouth,  and  larynx,  the  results  of  which  were  submitted  to  the  Berlin 
Leprosy  Congress  (1897),  must  be  regarded  as  among  the  most  valu- 
able of  the  recent  contributions  to  our  knowledge,  as  they  tend  to 
throw  light  upon  an  obscure  chapter  in  the  etiology  of  the  disease. 
Notwithstanding  the  identification  of  the  Hansen  bacillus  as  the  active 
pathogenic  agent  in  leprosy,  our  knowledge  of  the  sources  of  infec- 
tion and  the  channels  through  which  bacilli  gain  entrance  to  the  sys- 
tem is  by  no  means  definite. 

Several  years  ago  before  the  above-mentioned  investigations  were 
undertaken,  I  insisted  upon  the  precocity  of  the  mucous-membrane 
manifestations  of  leprosy,  asserting  that  in  a  majority  of  cases  they 
were  first  determined  toward  the  upjier  air  passages,  and  I  also  main- 
tained that  the  nasal  and  buccal  secretions  constituted  the  chief  source 
of  infection  in  leprosy. 

Jeanselme  and  Laurens  found  leprous  alterations  in  the  nasal 
mucous  membranes  in  sixteen  out  of  twenty-six  cases,  or  sixtj^  per 
cent.,  of  tubercular  leprosy.  These  alterations,  which  were  of  the 
nature  of  a  rhinitis,  attended  with  coryza,  obstruction  of  the  nostrils, 
epistaxis,  etc.,  constituted,  the^^  claimed,  the  first  signs  of  the  disease. 
The  bacteriological  examinations  of  the  nasal  secretions  furnished 
facts  of  the  greatest  interest  from  a  semeiological  point  of  view.  In 
the  mucus  of  the  leprous  rhinitis,  as  in  the  blood  of  the  epistaxis, 
Hansen's  bacillus  was  abundantl}^  found.  In  twelve  cases  it  was  i)os- 
sible  to  detect  the  specific  bacilli  at  the  first  examination.  Some  of 
the  cells  were  literally  crowded  with  microorganisms  having  the  mor- 
phological and  microchemical  characters  of  the  lepra  bacillus.  In 
others  the  bacilli  were  extracellular  and  disseminated  in  the  j^repara- 
tions,  but  they  were  always  agglutinated  in  great  numbers.  It  is 
worthy  of  note  that  the  bacilli  were  also  found  in  one  case  of  anaes- 
thetic leprosy. 

These  observers  claim  that :  "  The  most  important  deduction  to 
be  made  from  these  bacteriological  examinations  is  that  the  nasal 
mucus  of  lepers  is  of  very  great  virulence,  and  we  do  not  believe 
that  we  extend  legitimate  inductions  in  afiirming  that  rhinitis  is  one 
of  the  most  effective  sources  in  the  propagation  of  leprosy.  The 
contamination  is  effected  all  the  more  easilj^  as  the  leper  discharges 
a  great  number  of  bacilli  in  the  initial  period,  when  he  does  not  sus- 
pect the  nature  of  the  malady  and  persons  do  not  protect  themselves 
from  the  disease. 

"  The  same  maj^  be  said  of  the  leprous  lesions  of  the  mouth  and 
throat,  the  nature  of  which  is  often  not  recognized,  and  which  give  off 
almost  continually  a  multitude  of  bacilli." 

Schaffer,  of  Breslau,  demonstrated  that  vast  numbers  of  bacilli  left 


SOUKCES   OF   IXFECTION.  421 

the  body  by  way  of  tlie  diseased  mucous  membrane  of  tlie  moutli 
and  throat  of  the  leper  when  reading  aloud  or  talking.  The  number 
of  bacilli  projected  would,  of  course,  be  still  greater  in  the  acts 
of  sneezing  and  coughing.  The  importance  of  these  facts  from 
a  prophylactic  point  of  view  is  most  interesting,  and  they  coincide 
with  what  the  present  writer  emphasized  in  an  article  several  years 
ago :  "  In  view  of  the  fact  that  contamination  probably  takes  place 
from  the  nasal  and  buccal  secretions,  these  should  be  disinfected, 
etc.,  with  the  same  scrupulous  care  as  indicated  in  a  case  of  tuber- 
culosis." • 

The  investigations  of  Sticker  show  that  in  the  153  cases  examined 
by  him  evidences  of  the  presence  of  bacilli  in  the  secretions  of  the 
nasal  mucous  membranes  were  found  in  a  large  percentage  of  all  the 
oases.  Of  these  153  cases,  58  were  tubercular,  68  anaesthetic,  and 
27  mixed.  Of  the  58  tubercular  cases,  bacteriological  examination 
showed  the  presence  of  bacilli  in  all  but  2.  Of  the  68  anaesthetic 
cases,  only  23  contained  no  bacilli,  and  of  the  27  mixed  cases,  only  1 
was  free  from  bacilli.  He  concludes  that  the  primary  affection  or  its 
neighborhood  in  the  nose  is  chiefly  the  origin  from  which  the  bacilli 
regularly  and  in  enormous  numbers  are  given  ofl^  in  the  patient's 
proximity.  Only  the  purulent  sputum  of  a  few  lepers  (22  out  of  153) 
contained  such  enormous  numbers  of  bacilli  as  the  viscid  or  purulent 
secretion  from  the  diseased  nasal  mucous  membrane.  Not  even  the 
suppurative  nodules  can  compare  with  the  above-named  lesions  in 
the  spreading  of  the  bacilli.  Sticker  believes  that  the  nose  continues 
to  be  an  active  focus  for  the  projection  of  the  bacilli  during  the  entire 
course  of  the  disease,  even  during  the  periods  when  the  cutaneous 
manifestations  have  temporarily  disappeared. 

Physiological  Secretions. — The  physiological  secretions  may  con- 
tain bacilli  when  the  secretory  structures  are  the  seat  of  leprous 
changes,  or  they  may  serve  as  the  vehicles  of  the  virus.  The  saliva  is 
loaded  with  bacilli  when  the  leprous  lesions  are  situated  in  the  bucco- 
pharyngeal cavity.  The  bacillus  has  not  been  found  in  the  urine, 
although  the  Chinese,  according  to  Arning,  think  the  urine  is  espe- 
cially pathogenic. 

Pathological  Secretions. — The  altered  secretions  of  the  nasal  mucous 
membranes,  the  mucopus  and  blood,  the  discharges  from  broken-down 
nodules  and  ulcerating  surfaces  contain  the  bacilli  in  vast  numbers. 
It  is  a  question  whether  the  pathological  secretions  in  lepers  of  lesions 
not  produced  by  lejjrosy  contain  the  bacilli.  It  is  claimed  that  the 
serous  exudations  of  buUse  provoked  by  vesicatories  upon  the  skin 
of  lepers  have  been  found  to  contain  bacilli — a  statement  which  is 
contested  by  other  investigators.     In  addition  to  the  sources  of  in- 


422  MORROW — LEPROSY. 

fectiou  already  described,  it  is  probable  that  every  open  wound  or 
pathological  break  in  the  continuity  of  the  skin  may  afford  egress 
to  the  bacilli. 

In  advanced  cases  of  tubercular  leprosy  the  bacilli  arc  able,  ac- 
cording to  Babes,  to  penetrate  the  follicular  wall  from  within  outward 
aud  reach  the  surface  of  the  skin  when  the  latter  is  still  unbroken. 
It  would  appear  that  the  opportunities  for  the  escape  of  the  bacilli 
from  the  body  of  the  leper,  and  their  transference  directly  or  medi- 
ateh'  to  the  bodies  of  healthy  persons  with  whom  he  is  brought  in 
contact,  are  almost  innumerable.  The  only  explanation  of  why  con- 
tamination takes  place  so  rarely  under  such  favoring  conditions  is 
that  many  of  the  bacilli  are  dead  when  discharged.  Moreover,  the 
bacillus  leprjp  seems  to  be  a  weak  one,  and,  unless  introduced  in  a  tis- 
sue soil  favorable  for  its  growth,  it  does  not  germinate. 

Heredity  and  Contagion. 

A  belief  in  the  contagiousness  and  hereditary  nature  of  leprosy 
has  generally  prevailed  from  the  earliest  ages  until  tlie  present  cen- 
tury. The  earl}'  writers  among  the  Arabians,  Greeks,  Hindoos,  and 
others  have  recorded  their  belief  in  the  contagiousness  of  leprosj^ 
though  differing  as  regards  the  manner  in  which  it  occurs.  All  the 
proscrij)tive  measures  for  the  suppression  of  leprosy  formulated  in 
the  Levitical  code,  as  well  as  measures  for  the  isolation  of  lepers  in 
leper  houses  enforced  in  mediaeval  times,  were  based  upon  the  doc- 
trine that  the  disease  was  contagious.  The  segregation  of  lepers  in 
special  hospitals  and  communities  practised  in  many  countries  at  the 
present  day  is  based  upon  the  conviction  that  every  leper  is  a  source 
of  possible  danger  to  those  with  whom  he  maj'  come  in  contact. 

The  traditional  belief  that  the  disease  was  susceptible  of  hereditary 
transmission  has  never  l)een  questioned  until  comparatively  recently. 
In  all  ages  marriage  between  lepers  has  been  jirohibited  or  discoun- 
tenanced by  church  and  state.  In  mediaeval  times  not  only  was  it 
prohibited,  but  the  development  of  the  disease  in  one  partner  was  re- 
garded as  a  sufficient  pretext,  and  even  as  an  urgent  argument,  for  the 
dissolution  of  the  marriage  tie.  At  the  present  day,  in  many  coun- 
tries where  leprosy  is  endemic,  the  separation  of  the  sexes  in  leper 
asylums  and  the  interdiction  of  marriage  between  lepers  is  enforced 
b}'  government  authority. 

Within  the  past  half-century  the  doctrine  of  the  contagiousness  of 
leprosy  began  to  be  seriously  contested.  Daniellsen  and  Boeck,  who 
were  non-contagionists  and  were  strong  believers  in  heredity  as  the 
principal  factor  in  the  propagation  of  the  disease,  were  largely'  influ- 


HEKEDITY  AND  CONTAGION.  423 

ential  in  bringing  about  tliis  change  of  opinion.  In  this  view  they 
were  supported  by  the  prestige  and  high  authority  of  Virchow. 

In  1867  the  Royal  College  of  Physicians  of  London  promulgated 
the  dogma  that  leprosy  was  non-contagious.  "  The  all  but  unanimous 
conviction  of  the  most  experienced  observers  in  different  parts  of  the 
world  is  quite  opposed  to  the  view  that  leprosy  is  contagious  or 
inoculable  by  proximit}^  or  contact  with  the  disease.  The  evidence 
derived  from  the  experience  of  attendants  of  leper  asylums  is  espe- 
cially conclusive  on  these  points,  the  few  accidents  that  have  been 
reported  in  a  contrary  sense  usually  rest  upon  imperfect  observation 
or  they  are  recorded  with  so  little  attention  to  the  necessary  details  as 
not  to  afled  the  above  conclusion." 

This  opinion  was  generally  accepted  by  the  profession  in  Europe. 
As  an  evidence  of  how  complete  was  the  overthrow  of  the  doctrine  of 
contagion,  it  may  be  said  that  in  1885,  when  the  famous  discussion  of 
the  contagiousness  of  leprosy  took  place  in  the  Paris  Academy 
of  Medicine,  it  appears  that  only  three  physicians  in  France  upheld 
the  doctrine  of  contagion. 

With  the  elimination  of  what  had  been  regarded  as  the  principal 
factor  in  the  acquisition  of  leprosy,  it  is  not  strange  that  the  other 
factor  was  proportionately  magnified  in  importance  until  it  came  to 
be  believed  that  heredity  was  the  principal  agency  in  the  propagation 
and  production  of  the  disease.  According  to  many  leprologists  the 
influence  of  heredity  was  manifest  not  only  in  the  direct  line  from 
parent  to  offspring,  but  collaterally  as  well.  It  was  also  held  that  it 
might  skip  over  one  or  two  generations  and  reappear  in  the  descend- 
ants of  lepers  and  that  it  might  reappear  in  the  second  and  fourth 
generations  with  greater  force  than  in  the  first  and  third. 

The  sweeping  assertion  formulated  by  the  Royal  College  of  Phy- 
sicians, that  leprosy  was  non-contagious,  was  based  largely  upon 
negative  facts  of  contagion  while  ignoring  the  equally  numerous  posi- 
tive facts  wdiich  testified  to  the  contrary.  Although  the  doctrine  of 
contagion  was  generally  abandoned  in  Europe,  it  was  still  upheld 
by  many  observers  in  countries  where  leprosy  was  endemic.  A 
great  amount  of  clinical  evidence  was  accumulated  showing  a  vast 
number  of  instances  of  individual  and  epidemic  contagions.  The  de- 
velopment of  new  centres  of  lejjrosy  in  various  parts  of  the  world,  the 
positive  evidence  that  the  disease  never  originated  spontaneously, 
but  was  always  imported  by  lepers,  the  insufficiency  of  heredity  to 
explain  the  rapid  spread  of  the  disease,  the  observation  of  a  large 
number  of  Europeans  whose  ascendants  were  free  from  all  possible 
leprous  contamination  and  in  whom  there  could  be  no  specific  con- 
genital predisposition,  but  who  nevertheless  developed  the  disease 


424  MORROW — LEPROSY. 

after  sojourning  in  countries  where  leprosy  was  endemic — all  con- 
tributed to  foster  a  growing  scejiticism  in  heredity  as  an  important 
factor  until  professional  opinion  gradually  came  again  to  regard  con- 
tagion as  the  principal  factor  in  the  propagation  of  the  disease. 

In  1887  the  Eoyal  College  of  Physicians  modified  its  former  de- 
cision by  stating  "  the  committee  is  quite  aware  that  there  is  much 
difference  of  opinion  respecting  the  communicability  of  leprosy,  and 
that  many  colonial  practitioners  and  inhabitants  do  not  concur  in  the 
views  expressed  by  the  College  in  their  report  of  1867." 

In  1889  the  College  reconsidered  the  whole  (question  and  practi- 
cally recanted  its  earlier  opinion  in  the  statement  "  that  there  is 
undoubtedly,  as  the  committee  now  admits,  increasing  evidence  re- 
specting the  communicability  of  leprosy."  It  is  worthy-  of  note  that 
in  Norway  and  Sweden  many  of  the  former  opponents  of  the  doctrine 
of  contagion  have  now  become  its  most  ardent  advocates.  From  this 
review  of  the  changes  which  medical  opinion  has  undergone  in  refer- 
ence to  the  mode  of  communication  of  leprosy,  we  can  now  examine 
more  particularly  into  the  question  of  the  hereditary  nature  of  the 
disease. 

Is  Leprosy  Hereditary  ? 

It  is  scarcely  conceivable  that  a  disease  of  so  serious  a  nature  and 
which  so  profoundly-  impresses  the  system  should  not  exercise  some 
influence  ujion  the  offspring.  One  recognized  effect  of  leprosy,  es- 
pecially in  the  tubercular  form,  is  its  inhibitory  influence  upon  the 
procreative  power.  This  is  doubtless  due  to  the  azoospermia  which 
is  especially  marked  in  the  advanced  stage  of  the  tubercular  form,  al- 
though the  sterility  of  leprous  marriages  is  not  so  pronounced  as  has 
been  generally  assumed.  Clinical  evidence  would  seem  to  show  that 
the  influence  of  leprous  progenitors  upon  the  offspring  is  scarcely 
appreciable  in  the  early  stage,  but  becomes  manifest  at  a  more  ad- 
vanced stage  in  the  production  of  abortion,  or  of  delicate  children 
who  die  of  infantile  diarrhoea  or  succumb  to  various  slight  causes  of 
disease.  Abortion  usually  occurs  at  the  third  or  fourth  mouth,  often 
without  other  assignable  cause  than  foetal  cachexia,  or  the  infant  may 
be  still-born  at  full  term.  In  other  cases  the  child  is  l)orn  living,  but 
small,  ill-developed,  cachectic,  and  may  succumb  to  athrepsia  or  de- 
generative changes. 

It  has  been  generalh'  admitted  that  the  leprogenic  capacity  of 
progenitors  msLX  be  manifest  in  the  transmission  to  the  offspring 
of  a  constitutional  protoplasmic  state,  expressed  in  a  feeble  organiza- 
tion and  diminished  capacity  of  resistance  to  the  germs  of  disease  in 
general.     It  is  not  settled,  however,  that  there  is  transmitted  a  spe- 


HEREDITY  AND  CONTAGION.  425 

cific  congenital  predisposition  to  the  germs  of  leprosy  in  particular. 
In  an  article  already  quoted  I  wrote :  "  As  in  the  case  of  tuberculosis 
with  which  leprosy  j)resents  so  many  analogies,  the  influence  of 
heredity  is  probably  limited  to  the  creation  of  a  predisposition  to  the 
disease.  This  may  be  expressed  in  an  abnormal  susceptibility  to  the 
admission  and  pathogenic  action  of  the  bacilli  due  to  a  weak  consti- 
tution and  diminished  capacity  of  resistance  of  the  organism  inherited 
from  the  leprous  progenitor." 

A  more  careful  study  of  the  question  would  seem  to  indicate  that 
even  this  measure  of  influence  accorded  to  leprous  progenitors  is  a 
concession  not  warranted  by  the  facts,  since,  as  will  be  seen  later, 
there  would  seem  to  be  in  the  children  of  lepers  a  protective  immu- 
nization against  the  disease,  by  the  fact  of  the  leprosy  of  the  parents. 
The  evidence  v/hich  exists  is  hardly  sufficient  to  establish  an  inherited 
specific  predisposition  to  the  germs  of  leprosy  in  particular.  Besnier 
says  that  the  predisposition  of  children  of  leprous  parents  to  leprosy, 
if  it  exist,  is  certainly  less  accentuated,  less  particularized,  and  espe- 
cially^ less  characteristic  than  the  predisposition  of  children  of  tuber- 
culous parents  to  tuberculosis. 

The  question  whether  there  is  a  direct  transmission  of  leprosy 
from  parents  to  offspring  is  still  subjndice.  From  a  scientific  stand- 
point  the  acceiDtance  of  leprosy  as  a  parasitic  disease  is  hardly  recon- 
cilable with  the  theory  that  it  is  susceptible  of  transmission  by  the 
ovum  or  sperm  cell.  Hansen  declares  that  a  parasite  cannot  be 
transmitted  by  inheritance.  "It  maybe  handed  on  to  the  xihild  by 
the  parent,  but  in  a  different  sense  from  the  transmission  of  qualities 
primarily  embraced  in  the  sperm  cell  or  germ  cell.  To  speak  of  in- 
herited infection  is  a  contradiction  in  terms." 

It  is  evident  that  the  transmission  of  the  germs  of  a  disease  by 
direct  inheritance  must  take  place  by  the  sperm,  the  ovum,  or  through 
the  uteroplacental  circulation.  There  is  no  evidence  that  the  bacilli 
find  lodgment  in  the  seminal  cells,  and  from  the  comparative  rarity 
of  the  bacilli  in  the  ovary  and  in  the  female  organs  of  generation,  it 
is  doubtful  whether  they  are  found  in  the  ovum. 

Besnier  believes  that  in  the  rare  cases  in  which  direct  inheritance 
is  effected  it  is  by  the  uteroplacental  contamination  of  the  foetus. 
The  lepra  bacilli,  he  believes,  may  penetrate  the  placenta  by  way 
of  the  blood  current.  This  mode  of  contagion  he  terms  heredo-con- 
tagion.  It  must  be  remembered  that  the  presence  of  the  bacilli  in 
the  placenta  or  in  the  foetus  has  never  been  demonstrated.  The  only 
recorded  instance  of  an  attempt  to  find  bacilli  in  these  structures  was 
made  by  the  writer,  who  secured  the  placenta,  cord,  and  portions  of 
the  body  of  a  child  still-born  at  full  term  of  leprous  parents.     Care- 


426  MORROW — LEPROSY. 

t'ul  repeated  examinations  of  the  specimen  bv  Dr.  Fordvce  showed 
the  entire  absence  of  bacilli. 

As  regards  the  doctrine  maintained  by  Zambaco  Pacha  and  other 
leprologists,  that  the  germs  of  leprosy  may  be  inherited,  bnt  remain 
latent  and  appear  only  in  later  life  (fifty-five  to  fift}' -eight  years)  or 
reappear  in  succeeding  generations,  it  may  be  said  that  it  is  entirely 
opposed  to  our  knowledge  of  the  laws  of  heredity  and  the  pathogenic 
action  of  parasites.  It  involves  the  assumption  that  the  pathogenic 
bacilli  may  remain  inert  in  the  organism  for  one  or  more  generations 
and  be  transmitted  conceptionallj^  by  the  progenitors  who  are  them- 
selves uucontaminated.  Hansen  declares  that  the  atavic  transmission 
of  physiological  characters  is  not  reproduced  in  the  history  of  infec- 
tive diseases.  In  discussing  this  question  the  Indian  Leprosy  Investi- 
gation Committee  says :  "  In  the  study  of  embryological  deformities, 
atavism  may  be  of  great  importance,  but  if  the  term  is  employed  to 
denote  the  sudden  appearance  of  constitutional  diseases  after  having 
skipped  one  or  several  generations  it  is  inapplicable.  Atavism  has 
no  place  in  the  etiology  of  leprosy."  It  is  to  be  noted  that  all  alleged 
cases  of  atavic  inheritance  have  been  reported  from  countries  where 
leprosy  is  endemic,  with  more  or  less  numerous  centres  of  infection, 
and  where  there  were  infinite  chances  of  contagion  from  contact  with 
lepers. 

But  independent  of  theoretical  considerations  the  facts  of  observa- 
tion show  that  heredity  cannot  be  regarded  as  a  prominent  factor  in 
the  propagation  of  leprosy.  A  vast  number  of  statistics  have  been 
collected  from  various  sources  in  favor  of  the  doctrine  of  heredity. 
Nothing  shows  more  conclusively  the  misleading  nature  of  statistics 
than  the  wrong  interpretation  which  has  been  given  to  those  bearing 
upon  the  question  of  heredity.  The  conclusions  whicli  are  derived 
from  a  superficial  or  insufficient  observation  of  certain  facts  are 
entirely  traversed  hj  the  more  careful  study  and  a  more  intelligent 
interpretation  of  the  same  facts. 

One  or  two  sources  of  error  to  which  statistics  of  this  character 
are  liable  may  bo  here  i:)ointed  out.  The  defendants  of  the  doctrine 
have  been  accustomed  to  class  in  the  category  of  hereditary  transmis- 
sion all  cases  in  which  leprosy  occurs  in  the  descendants  irrespective 
of  the  age  at  which  the  disease  develops,  while  ignoring  the  multi- 
tudinous chances  of  infection  from  the  leprous  entourage. 

It  is  well  known  that  the  early  writers  on  syphilis  grouped  in  the 
category  of  hereditary  syphilis  all  cases  occurring  in  infants.  That 
they  made  no  distinction  between  congenital  and  acquired  infantile 
syphilis  is  evident  from  the  fact  that  they  speak  of  many  children  in 
whom  the  first  infection  occurs  in  the  mouth  or  on  the  face,  which 


HEKEDITY  AND  CONTAGION.  427 

cases  we  no-w  recognize  as  examples  of  tlie  acquired  form  of  tlie  dis- 
ease from  nursing  or  otherwise.  In  the  same  way  the  advocates  of 
heredity  speak  of  all  leprosy  in  children  as  inherited  without  elimi- 
nating the  possibilities  of  post-natal  contagion.  Statistics  show  that 
the  average  age  at  which  leprosy  develops  is  from  the  twenty-fifth  to 
the  thirtieth  year,  and  unless  we  concede  an  habitual  latency  of  the 
germs  during  this  i)rolonged  period,  it  is  evident  that  the  disease  in 
the  average  case  is  not  transmitted  by  inheritance. 

It  may  be  admitted  that  leprosy  is  more  common  among  the  chil- 
dren of  leprous  parents  than  among  those  of  healthy  parentage,  but 
this  fact  alone  does  not  necessarily  prove  that  the  disease  is  inherited. 
Leprosy  is  essentially  a  family  disease,  not  because  it  is  hereditary, 
but  because  it  is  contagious  and  because  in  family  life  contagion  more 
readily  takes  place.  It  may  be  restricted  to  one  or  several  definite 
groups  of  families  in  a  community  for  a  long  period,  but  the  oppor- 
tunities for  postnatal  infection  in  the  thousand  and  one  intimacies  of 
family  life  cannot  be  ignored,  and  a  closer  study  of  these  cases  shows 
that  the  occurrence  of  leprosy  among  them  is  more  reconcilable  with 
the  chances  of  accidental  contamination  than  the  theory  of  heredity. 

The  facts  which  may  be  invoked  in  favor  of  the  non-hereditary 
character  of  the  disease  may  be  considered  under  the  following  heads : 

(1)  Rarity  of  Congenital  Leprosy. — The  exceeding  rarity  or  com- 
plete default  of  cases  of  children  born  with  leprous  manifestations 
has  been  remarked  by  most  observers.  The  testimony  of  careful  and 
painstaking  observers  living  in  leprous  countries,  who  have  person- 
ally studied  the  disease  in  all  its  phases  for  years,  is  almost  without 
exception  to  this  effect. 

Daniellsen  and  Boeck  have  never  seen  leprosy  appear  before  the 
third  or  fifth  year.  They  state  that  lepers  have  come  to  them  saying 
.that  their  children  were  born  with  spots  or  with  bullae  of  the  extrem- 
ities, appearing  in  the  first  months  of  life,  but  personally  they  have 
never  seen  a  new-born  child  bearing  leprous  stigmata. 

Leloir,  in  his  extensive  personal  investigations  of  leprosy,  never 
found  a  fostus  or  new-born  child  affected.  Out  of  149  cases  only  3 
developed  leprosy  under  ten  years— at  four,  six,  and  eight  years  of 
age  respectively.  W.  M.  Jelly,  in  his  investigations  of  leprosy  in  the 
Spanish  provinces  of  Alicante  and  Valence,  searched  in  vain  for  a 
leprous  infant.  He  declares :  "  I  have  never  seen  or  been  able  to  find 
an  exanthematous  leprous  baby  or  child."  Falcao  found  in  709  cases 
only  3  as  early  as  four  years.  The  Leprosy  Commission  of  India 
found  in  2,371  cases  only  49  as  early  as  six  years.  Among  the  6,000 
or  more  cases  observed  in  Hawaii,  the  youngest  patient  was  three  and 
one-half  years  old.    In  Cape  Town,  Africa,  Impey  states  that  of  1,( 


428  MORROW — LEPROSY. 

cases  in  only  2  was  the  disease  developed  in  children  under  five  years 
of  age,  the  youngest  person  contracting  the  disease  being  three  years 
old.  It  would  be  easy  to  adduce  testimony  to  the  same  effect  from 
numerous  other  sources. 

In  the  article  to  which  reference  has  alreadj^  been  made  I  wrote : 
"There  is  no  well-authenticated  case  of  congenital  leprosy  on  rec- 
ord. Navarro  has  reported  a  case  of  congenital  leprosy  which  is  ap- 
parently one  of  inherited  syphilis.  Two  months  subsequent  to  the 
child's  birth  the  mother  showed  decisive  signs  of  leprosy,  as  did  also 
her  daughter  eight  months  later,  and  a  daughter  of  three  years  died 
two  years  later;  but  as  syphilis  is  bj^  no  means  excluded,  we  are  not 
bound  even  to  accept  this  as  a  decided  case  of  the  hereditary  trans- 
mission of  lei^ros}'." 

In  contravention  of  this  statement  the  only  observations  which 
may  be  regarded  as  of  a  positive  character  are  those  of  Zambaco 
Pacha,  reported  in  his  "  Yoj'^ages  chez  les  Lepreux."  He  admits  that 
congenital  leprosj^  appearing  a  short  time  after  birth,  some  months 
or  some  days,  is  exceedingly  rare.  Sometimes  one  child  in  a  family 
will  be  a  leper,  the  others  remaining  unaffected,  Avhile  in  other  cases 
one  child  may  remain  healthy  while  all  the  other  children  become 
lepers.  He  reports  a  number  of  cases  in  which  children  were  born 
with  undoubted  manifestations  of  the  disease.  It  is  to  be  noted,  how- 
ever, that  Zambaco  Pacha  denies  the  contagiousness  of  leprosy  and 
accords  the  first  place  to  heredity  in  the  spread  of  the  disease.  He 
also  denies  the  pathogenic  role  of  Hansen's  bacillus  and  asserts  that 
to  be  born  of  leprous  parents  or  to  belong  to  an  ethnical  group  in 
which  leprosy  is  endemic  would  be  sufficient  evidence  of  heredity. 

It  will  be  seen  that  according  to  the  testimony  of  the  most  com- 
petent observers  leprosy  is  not  manifested  in  the  offspring  until 
years  after  birth ;  very  exceptionally  as  early  as  the  third  year,  rarely 
before  the  fifth  or  sixth  year,  which  would  correspond  to  the  classical 
period  of  incubation  of  the  acquired  disease.  Even  conceding  the 
authenticity  of  Zambaco  Pacha's  cases  of  congenital  leprosy,  the  pro- 
portion of  such  cases  is  infinitesimally  small. 

Aye  at  ivh'wli  Leprofiy  DeveJoj^s. — In  quite  a  proportion  of  cases 
leprosy  may  be  first  evident  at  the  age  of  puberty,  from  the  twelfth  to 
the  fifteenth  year,  but  in  the  immense  majority  of  cases  it  does  not 
develop  before  the  thirtieth  year  of  age.  The  clinical  history  of 
leprosy  is  more  in  accordance  with  the  doctrine  of  contagion  than 
with  that  of  inherited  transmission.  The  incidence  of  the  disease  in 
the  children  of  leprous  parents  is  in  direct  ratio  to  their  exposure  to 
the  ordinary  sources  of  contagion. 

The  evidence  presented  in  favor  of  heredity  has  never  been  exclu- 


HEREDITY   A^T)    COXTAGIOX.  429 

sire  of  all  possibilities  of  i:iostnatal  contagion.  There  is  uo  case 
recorded  of  a  new-born  cliild  promptlv  removed  from  all  chances  of 
contact  -with  lepers,  wliich  later  showed  signs  of  the  disease.  In  all 
cases  of  so-called  heredity  there  is  everr  reason  to  believe. that  if  the 
children  had  been  iiromptly  removed  from  their  leprous  entourage, 
they  would  have  escaped  the  infection.  It  was  largely  because  of  the 
commonly  observed  exemption  of  the  offspring  of  lei^ers  from  the 
parental  disease  that  the  Kapiolani  Home  was  established  at  Hono- 
lulu. The  results  of  this  practical  scheme  of  separation  show  that  if 
children  are  removed  from  exposure  to  contaminating  contact  at  an 
early  age,  before  postnatal  infection  takes  place,  they  remain  free 
from  the  disease. 

The  Comparative  Rariiy  of  a  History  of  Leprous  Antecedents. — An- 
other argument  which  goes  to  show  that  the  inffuence  of  heredity,  if  it 
exist,  must  be  exceedingly  restricted  is  the  small  proportion  of  cases 
in  which  there  is  a  history  of  leprosy  in  the  iDarents.  According 
to  Impey,  there  are  at  present  (1896)  in  the  Eobben  Island  Asylum 
520  lepers,  of  whom  475  were  born  of  healthy  parents ;  of  the  remain- 
ing 45  cases,  the  father  alone  was  affected  in  25,  the  mother  in  16,  and 
the  father  and  mother  both  were  diseased  in  only  4.  Again  there 
are  2Q%  leper  parents  at  the  asylum  who  have  had  951  children.  Of 
these  children  23  became  leprous,  which  is  less  than  3  per  cent,  of  the 
whole. 

The  comparatively  small  proiDortion  of  children  (less  than  three 
per  cent.)  who  became  leprous  would  seem  to  indicate  that  the  exist- 
ence of  leprosy  in  parents  exercises  upon  the  offspring  a  protective 
rather  than  a  predisposing  influence  to  the  disease.  We  can  scarcely 
conceive  that,  of  an  equal  number  of  children  born  of  healthy  parents 
placed  in  this  leprous  environment  and  subjected  to  the  numerous 
chances  of  contamination  incident  to  the  intimate  contact  of  family 
life,  only  three  per  cent,  would  escape.  A^Tiether  there  has  been  in 
these  children  a  "  vaccinatory  immunization, "  as  it  has  been  termed, 
or  whether  there  is  a  greater  resisting  power  in  the  tissues  of  chil- 
dren against  the  lepra  germs  cannot  be  determined.  The  assertion 
that  the  lepra  bacilli  may  lie  latent  for  a  long  time  in  children  and 
not  develop  until  individual  resistance  is  lowered  is  purely  hypo- 
thetical. Certainly  these  facts  do  not  tend  to  favor  the  theory  of  a 
specific  predisposition  to  the  disease. 

The  statistics  of  the  Almora  Asylum  in  India  may  be  referred 
to.  Of  14  children  who  had  been  admitted,  1  had  died;  a  girl 
of  twenty-two  had  married  and  had  children  to  all  appearances 
healthy.  Of  the  remaining  12,  7  were  born  in  the  asylum,  of  two 
leper  parents,   and  5  were    the   offspring  of  parents,   both  lepers. 


430  MORKOW — LEPROSY. 

They  were  iu  excellent  health  aud  showed  no  signs  of  leprosy.  At 
Crete,  Carter  found  that  among  88  grown-up  children  of  lepers,  sev- 
eral thirty  years  of  age,  only  6  per  cent,  were  leprous.  Bracken  re- 
jiorts  that  of  34  Norwegian  lejiers  who  had  emigrated  to  this  country, 
21  are  known  to  have  been  married — 15  men  and  6  women.  These 
marriages  have  resulted  in  78  children,  not  one  of  whom  show  signs 
of  the  parental  disease.  Hansen,  who  in  1891  made  a  tour  of  investi- 
gation iu  the  Scandinavian  colonies  of  North  America,  found  that  of  the 
descendants  of  108  lepers  who  had  emigrated  from  Norway  to  this 
country,  not  oue  had  become  a  leper.  Dr,  Brockman  estimates  that 
there  must  be  in  Minnesota  alone  100,000  persons  with  leprous  an- 
cestors of  Norwegian  descent,  direct  and  collateral,  yet  leprosy  has 
never  appeared  among  them.  My  examination  of  numerous  lei)ers  iu 
Mexico  failed  to  reveal  the  history  of  hereditary  taint  in  a  single  in- 
dividual. 

Spread  of  Epidemics. — The  history  of  leprosy  in  the  Sandwich 
Islands  and  other  endemic  centres  shows  conclusively  that  the  rapid 
increase  in  the  number  of  lepers  is  vastly  disproportionate  to  the 
number  of  births  among  lepers.  Sterility  is  a  common  result  of  mar- 
riages among  Hawaiian  lepers.  Only  five  children  were  born  in  the 
leper  settlement  of  Molokai  within  ten  years,  although  no  restriction 
was  placed  upon  the  intermarriage  of  lepers.  In  1886  Mouritz  col- 
lected statistics  of  twenty -six  children  born  in  the  leper  settlement, 
whose  ages  ranged  from  three  to  fourteen  years.  Seventeen  of  these 
showed  no  sign  of  the  disease.  All  of  these  children  lived  under  the 
most  favorable  conditions  that  could  be  conceived  for  contracting  the 
disease,  and  it  is  altogether  i)robable  that  if  the  nine  who  became 
infected  had  been  removed  from  contact  with  their  leprous  parents  at 
an  early  age  they  would  have  escaped  the  disease. 

In  tracing  the  develoj^ment  and  spread  of  leprosy  in  the  Sandwich 
Islands,  a  careful  study  of  the  facts  shows  that  heredity  cannot  be 
considered  an  important  factor.  According  to  the  most  authentic 
accounts  the  first  case  of  leprosy  was  observed  about  1846.  Twenty 
years  later  several  hundred  lepers  were  sent  to  the  leper  settlement, 
a  large  proportion  of  whom  must  have  been  born  years  before  lep- 
rosy was  introduced  into  the  islands. 

When  we  consider  that  over  six  thousand  lepers  have  been  con- 
signed to  this  leper  settlement  since  its  establishment,  it  is  evident 
that  onl}'  a  very  small  contingent  could  have  been  the  offspring  of 
leper  parents. 

Finally  may  be  noted  the  numerous  cases  in  which  heredity  is 
impossible,  shown  by  the  fact  that  Europeans  who  have  lived  in 
countries  which  have  been  free  from  leprosy  for  centuries,  and  iu 


HEREDITY  AND  CONTAGION.  431 

whom  by  no  possibility  could  a  hereditary  taint  be  alleged,  acquire 
the  disease  when  sojourning  in  countries  in  which  leprosy  prevails. 

Another  argument  may  be  drawn  from  the  historical  fact  that  the 
Chinese  have  spread  leprosy  through  the  greater  part  of  the  Indian 
Archipelago,  Oceanica,  and  the  islands  of  the  Pacific.  The  many 
natives  and  foreigners  who  have  contracted  the  disease  are  not  of 
Mongolian  descent. 

Is  Leprosy  Contagious  ? 

As  before  intimated  in  reviewing  the  change  which  medical  opin- 
ion has  undergone  in  reference  to  the  etiology  of  leprosy,  the  doc- 
trine of  its  contagiousness  has  within  recent  years  regained  the 
ascendency  and  this  is  now  generally  regarded  as  the  principal  factor 
in  the  propagation  of  the  disease. 

The  discovery  of  a  specific  bacterium  which  is  invariably  and  ex- 
clusively found  in  the  bodies  of  lepers,  and  which  can  be  brought  into 
causal  relation  with  every  manifestation  of  the  disease,  gave  a  new 
aspect  to  the  question  of  contagiousness.  Even  before  the  demon- 
stration of  the  constant  presence  of  the  bacillus  leprs3  in  the  anatomi- 
cal elements  and  secretions  of  the  lejDrous  subject  there  was  abundant 
clinical  evidence  of  the  communicability  of  the  disease.  The  facts  of 
observation,  as  well  as  analogies  with  other  diseases  admittedly  con- 
tagious, rendered  it  difficult  to  conceive  how  a  disease  so  specific  in 
its  characteristics  could  develop  without  a  specific  cause.  Bacterio- 
logical research  simph^  confirmed  what  clinical  evidence  had  already 
demonstrated. 

The  contagiousness  of  leprosy  would  seem  to  be  a  necessary 
corollarj^  of  the  demonstration  of  its  parasitic  nature.  The  existence 
of  a  specific  bacillus  is  not,  however,  accepted  by  all  as  convincing 
proof  that  it  is  the  pathogenic  agent  and  that  it  is  transferred 
directly  by  contact  of  a  leper  with  a  healthy  person.  The  only  link 
wanting  in  the  chain  of  direct  evidence  is  that  the  modus  operajidi  of 
contagion,  the  actual  transference  of  the  bacillus  from  one  person  to 
another,  does  not  admit  of  positive  demonstration.  The  circumstan- 
tial evidence  is  sufficiently  comjjlete.  An  individual  affected  with 
leprosy  in  whose  lesions  the  bacilli  are  found  comes  into  more  or  less 
intimate  and  prolonged  contact  with  a  healthy  person  free  from  these 
germs.  By  and  by  the  latter  shows  symptoms  which  indicate  that 
he  has  been  the  recipient  of  the  germs  of  the  former — he  becomes 
leprous.  It  is  evident  that  in  some  way  or  manner  the  germs  from 
the  diseased  person  have  passed  into  the  healthy  organism  and 
infected  it.  This  infection  takes  place  under  certain  well-fixed  laws 
and  conditions  which  are  doubtless  peculiar  to  the  leprous  process. 


432  MORBOW— LEPROSY. 

It  is  probable  that  the  mode  of  contagiou  of  every  bacillary  disease  has 
au  iudividuality  of  its  own,  depending  partly  upon  the  germinative 
qualities  of  the  bacilli  causing  the  disease  and  partly  upon  the  soil 
that  these  organisms  re(iuire  for  their  development  and  the  comple- 
tion of  their  cycles  of  life. 

Whether,  as  has  been  suggested,  the  lepra  bacillus  undergoes  an 
evolutionary  change  outside  the,  human  bod}'  in  some  intermediary 
host  before  it  becomes  endowed  with  a  germinative  capacity  when 
brought  in  contact  with  human  tissues  is  immaterial  to  the  present 
inquiry.  The  hyi^othesis  of  an  intermediary  host  does  not  alter  the 
fact  that  the  bacillus  which  comes  from  the  leper's  body  is  the  essen- 
tial agent  of  contagion. 

Lhstaiices  of  Co)itagio)i. — The  literature  of  lejorosy  abounds  with 
well-authenticated  cases  of  individual  contagious,  showiDg  in  the 
clearest  and  most  positive  manner  that  the  disease  spreads  from 
leprous  to  healthy  persons  by  contact.  Thin,  in  his  work  on 
"Lepros}'"  (page  141  ctscq.),  has  quoted  more  than  sixty  well-authen- 
ticated observations  tracing  directly  the  communication  of  the  disease 
from  lepers  to  previously  healthy  persons  by  individual  contact  or  in 
family  life.     A  few  of  these  cases  may  be  here  given : 

At  Grenada,  a  girl,  aged  about  twelve  to  fourteen,  slei:)t  in  the 
same  bed  with  a  young  woman  who  had  symptoms  of  leprosy. 
Within  twelve  months  the  girl  had  a.  leprous  rash,  and  was  a  con- 
jfirmed  leper  seven  or  eight  years  afterwards.  The  mother  of  this  girl 
contracted  the  disease ;  the  father  escaped. 

A  healthy  girl,  aged  seven,  slept  in  the  same  bed  with  a  bo.y,  aged 
nine,  who  was  leprous,  and  she  became  affected  with  leprosy. 

Dr.  Davy  cites  the  case,  on  the  authority  of  the  medical  officer  of 
Trinidad  Hosj^ital,  of  a  man  who  became  a  leper  after  two  children 
had  been  born  to  him.     Afterwards  these  children  became  leprous. 

A  European  officer  in  India  became  leprous  when  he  was  forty- 
five,  and  within  two  years  had  developed  the  full  stage  of  tubercular 
leprosy.  His  large  family  and  many  relations,  as  well  as  parents, 
were  perfectly  healthy. 

A  boy  lived  with  an  apothecary  who  was  a  leper,  and  became 
leprous.  A  convict,  acting  as  orderly  to  the  same  apothecary,  became 
affected  with  the  disease  and  died  within  a  year  of  the  first  appear- 
ance of  the  affection. 

A  European,  who  was  a  leper,  stated  that  he  had  contracted 
the  disease  from  a  favorite  servant  who  was  constantly  about  his 
person. 

A  child  wh(;se  ])arents,  grandparents,  and  four  brothers  and  sis- 
ters were  healthy  was  the  favorite  of  a  leper,  the  brother  of  his  grand- 


HEEEDITT  AND  CONTAGION.  433 

father,  and  frequentlj  slept  in  tlie  same  bed  witli  liim.  He  became 
affected  witli  leprosy. 

A  woman  in  whose  family  it  was  known  that  for  three  generations 
there  was  no  leprosy  was  sent  when  a  child  to  Eze,  County  of  Nice, 
to  be  wet-nursed  by  a  woman  who  appeared  to  be  healthy,  but  in 
whose  family  there  had  been  cases  of  leprosy.  On  the  woman  her- 
self, immediately  after  the  child  was  weaned,  leprous  manifestations 
were  observed.  The  child  grew  up  and  became  leprous  in  mature 
years.  She  married  and  had  four  children.  Her  husband  and  two 
daughters,  who  died  young,  had  no  lepros}".  The  other  two  children 
(sons)  have  since  died  lepers.  Of  these  sons  there  is  the  following 
history  :  One  developed  symptoms  of  leprosy  when  doing  his  mili- 
tary service,  after  having  left  Eze.  He  died,  aged  twenty-eight,  of 
lepros3^  His  brother  died  of  leprosy  at  fifty.  His  wife  still  lives 
and  is  well.  He  had  been  long  in  intimate  relations  with  a  woman 
who  came  from  the  north  of  France,  and  who  belonged  to  a  family  in 
which  there  was  no  leprosy.  This  woman  and  one  of  her  sons,  who 
had  been  much  associated  with  the  man,  became  leprous  three  years 
after  he  showed  symptoms  of  the  disease. 

A  family  named  Quin,  consisting  of  a  father,  mother,  and  five 
children,  all  in  good  health  and  free  from  leprous  taint,  left  Nice  for 
St.  Laurent  d'Eze.  There  they  associated  daily  with  a  family  of 
lepers.  They  had  meals  in  common  and  slept  on  straio  in  the  same 
granary.  After  six  years  of  this  intimacy  leprosy  appeared  in  the 
family  of  Quin.  The  mother  and  five  children  successively  died  of 
leprosy,  and  the  father  has  just  died  of  leprosy  in  the  hospital  at 
Nice. 

The  village  of  Turette,  situated  on  the  right  bank  of  the  Paillon 
river  of  Nice,  was  free  from  leprosy  until  1815.  At  that  time  a  fam- 
ily Mas took  a  servant  who  was  a  leper.     From  this  patient 

leprosy  was  conveyed  gradually  to  nine  persons.     The  household 

Mas ,    husband  and  wife,    were  attacked  first;    then   a  family 

Gar ,  who  had  frequent  relations  with  the  Mas .     A  cousin  of 

the  Gar family,  who  lived  with  them,  was  also  affected,  as  well 

as  his  wife.  His  three  children  still  live  at  Tourette,  and  are  lepers. 
One- of  the  latter,  having  long  lived  in  a  shepherd's  hut,  made  a  pres- 
ent of  the  cabin  in  which  he  had  slept  to  a  shepherd  belonging  to  a 
healthy  family.  This  shepherd  lived  in  the  cabin  for  a  long  time. 
He  is  now  a  leper. 

According  to  Simond,  quoted  by  Forne,  fourteen  convicts,  trans- 
ported to  Guiana,  thirteen  of  whom  were  born  in  France  and  one  in 
Algiers,  became  leprous  after  they  were  set  free. 

A  Sister  of  Mercy,  born  in  France  of  healthy  parents,  and  who 
Vol.  XVIII.— 28 


434  MORROW — LEPROSY. 

had  excellent  health  until  she  was  forty-six  years  of  age,  came  to 
French  Guiana  in  1862.  Five  years  after  her  arrival  there  she  be- 
came attached  to  the  service  of  the  lazaretto  of  Acarouany,  where  she 
was  occupied  in  attending  to  lepers  in  various  ways.  In  1878,  at  the 
age  of  forty -six,  after  having  been  eleven  years  in  the  lazaretto,  she 
experienced  the  first  symptoms  of  leprosy,  and  in  1883  was  in  the  last 
stage  of  the  disease.  She  believed  she  had  been  infected  by  washing 
linen  beloDging  to  leper  women ;  but  Dr.  Hulin  do  Godon  stated  that 
the  Sister  became  leprous  after  having  pricked  her  fingers  with  a 
needle,  which  she  had  used  in  sewing  le^iers'  clothes. 

A  European  Sister  of  Mercy,  free  from  heredi^ry  taint,  who  was 
occupied  in  the  linen  room  of  the  hospital  at  Tahiti,  inoculated  her- 
self with  a  sewiug-needle  under  the  same  condition  as  the  Sister  at 
Guiana.     Se  was  sent  home  to  France,  in  1885,  a  leper. 

A  European  child,  nine  years  old,  free  from  taint,  associated  with  a 
leprous  colored  child.  During  their  play  the  leprous  child  took  a 
pin  or  penknife  and  thrust  it  into  the  aneesthetic  skin  of  his  leg  with- 
out experiencing  pain.  The  astonished  white  child  repeated  the 
experiment  on  himself,  causing  severe  pain.  He  was  afterwards  sent 
to  Holland  to  be  educated,  and  returned,  when  nineteen  years  old,  to 
Java,  a  confirmed  leper,  the  disease  having  appeared  two  j-ears  before 
his  return.  The  gentleman  was  well  known  in  Batavia,  and  the  case 
was  clearly  either  one  of  contagion  or  inoculation. 

Sir  William  Moore  relates  that  when  he  was  stationed  in  India  he 
had  the  patients  (some  of  whom  suffered  from  leprosy)  who  were 
affected  with  itch  rubbed  with  sulphur  ointment  at  the  dispensar3^ 
One  of  the  persons  employed  to  do  this  injured  her  hand  and  after- 
wards developed  leprosy,  her  family  being  quite  free  from  the  mal- 
ady, and  no  history  of  other  association  with  le^iers  being  obtainable. 

Prof.  Cayley  relates  that,  in  1886,  the  leper  ward  at  Burdwan 
jail  contained  about  thirt}"^  lepers.  During  the  twelve  months  that  he 
was  in  charge  of  the  jail  two  persons  who  had  been  there  four  or  five 
years,  and  who  were  selected  as  healthy  men,  were  put  in  charge  of 
the  leper  ward  and  were  attacked  with  lepros3\ 

A  white  girl,  aged  fifteen,  of  good  family,  without  leprosj^  taint, 
accepted  an  invitation  from  a  young  friend,  members  of  whose  family 
were  lepers,  the  fact  being  concealed.  The  girls  slept  in  the  same 
bed,  and  lived  intimately  together.  After  three  months  the  girl  be- 
longing to  the  leprous  family  left  her  friends,  and  some  time  after- 
wards the  disease  made  its  appearance.  The  girl  who  was  invited 
grew  up  to  womanhood,  married,  and  had  children;  but  after  a  few 
years  the  disease  attacked  her,  and  she  died  a  leper. 

A  boy  belonging  to  a  clean  family  used  to  play  and  sleep  with  a 


HEEEDITY  AND  CONTAGION.  435 

boy  who  belonged  to  a  family  in  whicli  there  was  leprosy.  The 
tainted  boy  soon  became  a  leper,  and  three  years  afterwards  his  play- 
fellow, in  whose  family  there  was  taint,  became  leprous. 

A  white  man,  aged  twenty-five,  was  on  intimate  terms  and  slept 
with  a  young  man  who  had  leprous  spots.  In  the  course  of  about  a 
year  the  previously  clean  man  found  spots  on  his  person,  and  died 
in  a  short  time  of  leprosy.  His  family  was  and  remained  free  from 
all  taint. 

A  young  colored  boy,  of  clean  family,  while  suffering  from  an 
eruption,  played  with  a  boy  who  was  a  leper  and  had  a  suppurating 
ulcer  in  the  foot.  The  previously  healthy  boy  became  a  leper  about 
a  year  afterwards,  his  family  remaining  untainted. 

A  young  Scotchman,  whose  parents  had  never  left  Europe,  was 
contaminated  by  a  leper  woman.  Within  ten  months  he  developed 
leprous  spots  and  died  a  leper. 

A  colored  man,  a  leper  of  Kaoo  Island,  stated  that  he  attributed 
his  disease  to  the  fact  that  his  mother  washed  the  clothes  of  several 
lepers  and  used  to  wash  his  along  with  them.  He  stated  that  his 
parents  and  relations,  so  far  as  he  knew,  were  free  from  leprosy. 

Dr.  Liveing  relates  that  a  soldier  who  had  served  in  India  died  in 
Guernsey,  and  that  in  his  last  illness  he  had  sores  on  his  fingers  and 
toes,  an  enlargement  of  the  nose,  and  discoloration  on  the  skin  of  the 
face.  One  of  this  man's  sons,  when  fifteen  years  old,  developed 
leprosy. 

The  only  case  except  that  of  Dr.  Hawtrey  Benson  that  we  have 
found  recorded,  in  which  the  disease  must  have  been  communicated 
in  England,  is  that  published  in  Guy's  Hospital  Eeports  for  1868, 
and  referred  to  by  Munro.  Johanna  Crawley,  an  Irishwoman,  aged 
thirty-four,  had  lived  thirty  years  at  Stepney.  In  1866  she  had  lost 
part  of  the  first  finger  of  the  right  hand.  On  her  body  and  limbs 
were  large  brown  patches,  and  there  was  decided  anaesthesia  as  far  up 
as  the  elbows.  The  face  was  puffy,  the  lips  and  ears  were  swollen. 
Munro  saw  her  daughter  at  Stepney,  a  woman  aged  twenty-five,  and 
was  informed  by  her  that  Johanna  died  in  1874,  after  losing  part  of 
all  her  fingers  and  toes,  the  blisters  and  destruction  of  bone  causing 
great  pain. 

A  widow,  aged  fifty-eight,  with  several  children,  went  to  live  with 
a  daughter  who  was  a  leper,  and  was  attacked  five  years  afterwards 
when  she  was  sixty-five  years  of  age. 

In  St.  Kitts,  Hannah  Carty,  when  a  girl,  slept  with  and  washed 
the  clothes  of  T.  Wilson,  who  was  covered  with  leprous  sores.  She 
was  attacked  at  the  age  of  seventeen.     Her  family  were  all  healthy. 

Epidemic  and  Endemic  Contagions. — When  leprosy  invades  a  new 


436  MORROW — LEPROSY. 

counh'T  or  a  commimitr,  which  is  biit  an  aggregation  of  individuals, 
the  same  mode  of  contagion  is  manifestc  It  spreads  from  individual 
to  individual  b}-  proximity  or  contact.  The  primarj^  essential  condi- 
tion of  the  development  of  leprosy  in  a  country  or  race  pre%-iously  ex- 
empt is  the  importation  of  leprous  germs  in  the  body  of  a  leper  who 
becomes  a  centre  of  contagion,  and  creates  new  foci  of  the  disease 
around  him.  The  disease  spreads  more  or  less  rapidly,  assuming 
epidemic  proportions  or  becoming  circumscribed  in  small  endemic 
foci  according  as  the  conditions  are  more  or  less  favorable.  When 
introduced  into  a  virgin  soil,  as  in  the  Sandwich  Islands  for  example, 
where  the  racial  susceptibility  to  disease  is  marked  and  the  conditions 
for  its  multiplication  are  favored  by  promiscuity  in  the  habits  of  eat- 
ing, drinking,  and  sleeping,  and  where  free  and  intimate  contact  with 
the  leper  is  restrained  by  no  wholesome  fear  of  the  disease,  it  spreads 
with  exti'aordinary  rapidity  and  shows  all  the  characteristics  of  a 
virulent  epidemic. 

WTien  imported  into  countries  of  advanced  civilization,  in  the 
United  States  or  Central  Europe  for  example,  whsre  the  physical 
stamina  is  of  a  higher  order,  where  the  rules  of  personal  hygiene  and 
sanitary  living  are  observed,  and  where  public  sentiment  or  popular 
prejudice  looks  upon  the  leper  as  the  bearer  of  a  deadly  contagion  to 
be  shunned  and  avoided,  lej^rosy  rarely  spreads,  and  contagion  can 
scarcely  be  said  to  exist. 

In  countries  where  leprosy  has  been  endemic  or  maintained  in 
permanence  for  generations  or  centuries  it  will  be  found  that  its  lim- 
itation or  spread  is  largely  influenced  by  the  more  or  less  free  con- 
tact of  the  leprous  with  the  healthy.  Where  public  opinion  has 
inculcated  a  wholesome  dread  of  the  disease  or  where  governmental 
authority  has  taken  measures  of  isolation  and  protection  the  disease 
is  circumscribed  and  limited ;  in  countries  where  neither  law  nor  pub- 
lic opinion  prevents  the  free  intermingling  of  lepers  with  the  healthy 
of  the  community  the  disease  siDreads. 

In  India,  Mr.  McNamara  says:  "Although  lepers  move  about 
among  their  countrymen,  they  are  to  a  great  extent  isolated  from 
them.  )iMio  ever  saw  a  healthy  native  touch,  much  less  eat  with,  one 
afflicted  with  leprosy?  In  many  parts  of  India  the  fact  of  admit- 
ting a  leper  to  a  general  hospital  is  sufficient  to  drive  every  other 
person  out  of  it.  The  wealthy  leper  may  purchase  immunity  from 
some  of  the  social  evils  to  which  his  poorer  brethren  are  exposed; 
but  even  he  is  frequently  obliged  to  leave  house  and  home  and  wan- 
der as  an  outcast  over  the  face  of  the  earth,  visiting  shrines  and  holy 
places  in  expiation  of  his  sins  which  he  believes  have  been  punished 
by  the  infliction  of  leprosy.     Rich  and  poor  lepers,  however,  though 


HEEEDITY  AND  CONTAGION.  437 

living  and  moving  among  their  fellow-men,  are  as  isolated  from  tliem 
as  vi^ere  those  condemned  to  the  lazar  houses  in  the  Middle  Ages. 

Of  interest  in  this  connection  are  Vandyke  Carter's  observations  of 
the  method  of  dissemination  of  leprosy  in  India.  "  Taking  the  more 
infected  districts,  we  find  that  while  much  of  the  surface  is  covered 
by  disease,  yet  the  leper  villages  are  not  indiscriminately  scattered. 
Thus  the  chief  town  always  represents  a  chief  '  focus  ' ;  nest  the  vil- 
lages immediately  around  are  affected,  and  beyond  these  pass  off,  as 
it  were,  lines  of  leper  localities  in  various  directions  which  may  meet 
and  blend  or  become  continuous  with  similar  lines  in  adjoining  dis- 
tricts. At  present  I  find  hardly  a  single  instance  in  which  a  leper  vil- 
lage does  not  form  either  a  focus  or  a  part  of  lines  or  groups  such  as 
those  now  mentioned.  No  leper  village  is  found  to  be  isolated ;  all 
are  connected  with  others  immediately  adjoining,  the  rare  uninfected 
intervening  villages  being  temporary  or  incidental  exceptions.  All 
these  data  may  be  said  to  point  to  transmission  of  the  leprous  disease 
by  human  intercourse — that  is,  by  contagion." 

The  opponents  of  contagion  base  their  belief  largely  upon  the  fail- 
ure of  all  attempts  to  inoculate  the  disease,  the  observations  of  numer- 
ous persons  who  have  lived  in  prolonged  contact  with  lepers  without 
having  contracted  the  disease,  as  for  example  physicians,  Sisters  of 
Charity,  nurses,  and  attendants  who  have  come  in  contact  with  lepers 
in  hospitals,  the  comparative  infrequency  of  conjugal  contamination, 
the  failure  of  leprosy  to  spread  when  imported  into  certain  countries, 
and  finally  the  fact  that  leprosy  does  not  comport  itself  as  a  contagi- 
ous disease.     These  objections  may  be  considered  in  detail. 

Failure  of  Inoculation  Experiments  in  Animals. — The  result  of  ex- 
perimental attempts  in  inoculating  animals  is  a  record  of  failures 
simply  because  leprosy  is  an  exclusively  human  disease.  The  tissues 
of  the  human  species  furnish  a  culture  soil  favorable  to  the  reception 
and  development  of  the  pathogenic  agent,  while  the  tissues  of  ani- 
mals are  immune. 

The  proposition,  that  because  a  disease  cannot  be  inoculated  in 
animals,  it  therefore  cannot  be  transmitted  from  man  to  man,  would 
be  equivalent  to  a  denial  of  the  contagious  nature  of  many  diseases 
admittedly  contagious.  There  is  no  well-authenticated  proof  of  the 
inoculation  in  animals  of  syphilis,  which  may  be  considered  the  type 
of  an  inoculable  disease.  Besides,  all  experience  shows  that  nothing 
is  more  difficult  than  inoculating  animals  with  human  diseases.  The 
failure  may  in  many  instances  be  due  to  our  ignorance  of  the  precise 
conditions  which  determine  the  vegetability  of  disease  germs.  As  is 
well  known,  the  earlier  attempts  to  inoculate  the  products  of  tubercu- , 
losis  were  failures. 


438  MORROW — LEPROSY. 

Failure  of  Atfempfs  to  Iiiocniafe  Blan. — While  the  results  of  these 
experiments,  which  are  elsewhere  referred  to  in  detail,  were  simply 
negative,  they  cannot  be  considered  absolutely  demonstrative  of  the 
impossibility  of  inoculating  leprosy  in  man.  It  must  be  remembered 
that  they  Avere  undertaken  at  a  period  when  the  bacteriology  of  the 
disease  was  unknown,  and  with  no  attention  to  technical  details  which 
are  now  deemed  essential  in  experimental  imjuiry,  or  it  is  possible 
that  the  systems  of  the  healthy,  well-fed  individuals  who  were  subjected 
to  experiment  were  not  in  a  condition  to  conceive  and  develop  the 
]iathogenic  action  of  the  bacilli.  As  Besnier  suggests,  "  one  should 
not  forget  that  the  iusuccess  of  an  inoculation  often  depends  upon  the 
ignorance  of  the  experimental  conditions  attached  to  the  special  mode 
of  contagiosity  peculiar  to  the  affection" ;  further,  "  if  experiments 
upon  man  were  lawful  at  the  present  day,  absolute  demonstration 
would  not  be  long  in  forthcoming. "  The  only  case  in  which  inocula- 
tion from  man  to  man  was  claimed  to  be  successful  was  that  of  Keanu, 
elsewhere  referred  to. 

Unless  we  single  out  leprosy  as  an  exception  to  other  infectious 
diseases,  the  negative  facts  of  inoculation  experiments  cannot  be  con- 
sidered proofs  of  its  non-contagiousness.  It  is  well  known  that  the 
germs  of  diphtheria,  scarlatina,  cholera,  typhoid  fever,  etc.,  have 
never  been  inoculated  in  man,  but  this  negative  evidence  cannot  be 
considered  as  proof  of  their  non-infectious  character. 

Keference  might  be  made  to  the  repeated  attempts  to  inoculate 
favus  in  man  and  the  uniform  failure  of  all  the  earlier  attempts  to 
transfer  the  disease  from  one  host  to  another.  The  question  of  vac- 
cination leprosy  has  an  important  bearing  upon  the  determination 
of  the  possibility*  of  inoculating  the  disease  and  will  be  considered 
later  in  connection  with  the  modes  of  infection. 

My  own  belief  is  that  leprosy  is  inoculable  in  man,  and  that  w^e 
have  abundant  clinical  proof  that  accidental  inoculations  play  an  im- 
portant role  in  the  introduction  of  the  germs. 

Rarity  of  Conjugal  Contamination. — The  concurrent  testimony  of 
many  observers  in  various  parts  of  the  world  where  leprosy  is  endemic 
shows  that  when  one  partner  of  a  marriage  is  a  leper  the  incidence  of 
the  disease  in  the  other  partner  is  surprisingly  small,  on  the  assump- 
tion that  contagion  takes  place  from  intimate  contact.  Besnier  dis- 
poses of  the  whole  question,  especially  of  the  cases  in  which  a  healthy 
woman  has  borne  children  to  a  leprous  man  wdiile  she  herself  shows 
no  signs  of  the  disease,  on  the  ground  that  the  immunity  of  the  wom- 
an is  not  a  fact  of  non-contamination,  l)ut  a  fact  of  conceptional  im- 
munization comparable  to  Avhat  is  realized  in  conceptional  syphilis, 
as  formulated  in  the  law  of  Colles.     It  may  be  urged  against  this  in- 


HEEEDITT  AND  COXTAGIOX.  439 

terpretation  that  it  takes  no  account  of  the  e4iially  large  and  perhaps 
larger  number  of  eases  in  which  a  healthy  man  is  married  to  a  leprous 
woman,  or  has  relations  -u-ith  numerous  leper  "n-omen,  without  being 
contaminated. 

I  have  reported  the  case  of  a  Hawaiian  who  had  been  the  husband 
of  a  leprous  woman  for  twenty-nine  years,  two  daughters  of  this 
union  both  being  leprous,  while  he  remained  absolutely  fi'ee  from  all 
signs  of  the  disease.  This  was  probably  a  case  illustrating  absolute 
immunity,  as  the  entire  family  lived  in  the  leper  settlement,  and  the 
opportunities  for  extra-conjugal  contagion  were  numerous.  Many 
instances  of  similar  character  came  under  my  observation,  as  my  at- 
tention was  particularly  directed  to  this  class  of  cases,  since  they 
were  in  opposition  to  the  opinion  which  generally  prevailed  among 
the  i)hysicians,  as  well  as  the  laity,  of  Hawaii,  that  the  disease  was 
commonly  propagated  by  sexual  intercourse. 

An  explanation,  though  in  my  opinion  an  insufficient  one,  of  this 
frequent  immunity  from  marital  contagion  has  been  sought  in  the 
fact  that  the  age  at  which  lepers  marry  corresponds  to  a  period  in 
which  the  susceptibility  to  the  disease  is  markedly  diminished.  An 
analysis  of  a  large  number  of  cases  shows  that  the  susceptibility  to 
the  disease  is  particularly  marked  from  the  twentieth  to  the  thirtieth 
year.  After  the  thirtieth  year  the  tendency  progressively  decreases, 
so  that  leprosy  is  apt  to  attack  the  man  before  the  age  of  marriage, 
and  as  it  often  saps  the  virility,  especially  in  tubercular  cases,  the 
wife  incurs  no  additional  risk  to  that  of  any  other  person  in  contact 
with  a  leper.  It  is  claimed  that  "  when.leprosy  occurs  after  marriage, 
by  the  time  the  man  is  able  to  communicate  the  disease  his  wife  has 
from  her  age  become  in  most  cases  insusceptible." 

Too  much  importance  should  not  be  attached  to  explanations  of 
this  nature,  as  observations  prove  most  conclusively  that  lejjrous  con- 
tamination in  maiTiage  is  by  no  means  uncommon.  It  must  be  re- 
membered that  in  its  mode  of  contagion  leprosy  resembles  tubercu- 
losis rather  than  syphilis.  It  is  a  matter  of  general  observation  that 
consumption,  an  admittedly  contagious  disease,  is  rarely  inarital, 
while  syphilis  is  almost  always  shared  with  the  partner  in  maniage. 

A  few  of  the  numerous  cases  recorded  in  literature  which  show  in 
the  most  positive  manner  that  the  wife  or  husband  has  contracted  the 
disease  from  the  other  during  marriage  may  be  here  quoted. 

The  following  cases  are  taken  from  the  reports  to  the  Government 
of  India  and  other  well-authenticated  sources  ("Leprosy,"  Thin,  pp. 
139  et  seq.) : 

A  girl,  in  whose  family  there  was  no  trace  of  leprosy,  married  a 
leper,  and  after  some  years  became  leprous. 


440  MORROW — LEPROSY. 

A  sweeper,  who  belonged  to  a  family  iu  which  there  was  no  lep- 
ros}',  married  a  leper  woman,  and  himself  became  a  leper. 

A  weaver,  whose  father  and  elder  sister  were  lepers,  became  lep- 
rous at  thirty.  His  wife  continued  to  live  with  him  and  eventually 
became  a  leper. 

A  weaver  became  a  leper  at  forty -five.  His  wife  continued  to  live 
with  him  and  became  leprous. 

A  cultivator  became  leprous  at  forty-eight.  His  wife  became 
affected  with  leprosy  a  year  later. 

A  man  became  a  leper  at  thirty-two,  his  brother  being  a  leper. 
His  wife  lived  with  him  for  two  jears  afterwards  and  became  leprous. 

A  woman,  whose  grandfather  and  father  were  lepers,  became  a 
leper  at  twenty-eight.  Her  husband,  who  lived  with  her  a  year  after- 
wards, became  affected. 

A  sweeper  became  a  leper  at  eighteen,  and  his  wife  was  afterwards 
affected. 

A  woman,  whose  father  died  of  leprosy,  became  affected,  and  her 
husband  developed  leprosy  the  following  year. 

Deputy  Surgeon-General  Cockburn  states  that  he  had  seen  a  wife 
with  her  two  children  contract  the  disease  by  remaining  with  her  hus- 
band, who  was  affected  by  it,  while  three  other  children  who  left  him 
remained  free. 

Greene  states  that  he  has  seen  several  instances  at  Sehampore 
Hospital  in  which  the  disease  was  acquired  by  sexual  intercourse. 

Ghose  relates  a  case  of  a  woman  who  became  leprous  after  her 
,  husband.  When  he  died,  she  went  to  live  with  her  brother,  and 
within  a  year  the  brother  acquired  leprosy.  In  the  course  of  six 
years  three  other  individuals  in  neighboring  houses  got  the  disease. 
Ghose  was  assured  that  before  this  woman  returned  home  after  her 
husband's  death  there  had  not  been  a  leper  in  that  village. 

Van  Hoist  relates  the  case  of  an  officer  in  Dutch  Guiana  who  con- 
tracted leprosy  from  cohabiting  with  a  woman  whose  family  were 
affected  with  the  disease. 

Two  instances  at  Corfu  are  related  iu  which  the  wives  became  lep- 
rous some  years  after  the  husbands. 

At  Mauritius,  a  case  is  related  in  which  a  wife  became  affected 
after  her  husband,  and  another  in  which,  after  a  man  became  a  leper, 
the  child  of  his  wife  by  a  former  husband  became  affected. 

An  Englishman  in  British  Guiana  cohabited  with  a  colored  woman 
and  became  leprous.  The  woman  had  not  been  suspected  of  leprosy, 
although  afterwards  it  was  found  that  she  had  had  the  spots  on  her 
body  previously.  One  of  her  sisters  was  leprous,  and  the  woman's 
child,  when  five  years  old,  exhibited  signs  of  the  disease. 


HEREDITY   AND   CONTAGION.  441 

A  wliite  man,  aged  twenty -five,  became  a  leper  after  sleeping  in 
the  same  bed  and  using  the  same  pipe  with  a  leper. 

A  man,  soon  after  the  birth  of  his  first  child,  discovered  that  his 
wife  was  a  leper,  and  shortly  afterwards  became  one  himself.  His 
children  remained  free. 

A  girl  belonging  to  a  leprous  family  of  Laghet  left  her  home  when 
twelve  years  of  age  and  became  a  servant  at  Nice.  When  she  was 
twentj'-two,  and  in  perfect  health,  she  married  a  healthy,  strong  young 
man  from  the  north  of  France.  She  was  nineteen  years  old  when  her 
father  first  showed  signs  of  leprosy.  When  she  was  twenty-seven 
years  old  she  had  leprous  tubercles  below  the  left  breast,  and  died  at 
the  age  of  thirty  at  the  hospital  at  Nice.  Two  years  after  the  death 
of  his  wife  the  husband  showed  leprous  development  in  the  face,  and 
died  of  the  disease  three  years  later. 

An  Englishman,  whose  parents  never  left  Europe,  lived  with  a 
woman  who  some  time  afterwards  showed  symptoms  of  leprosy.  The 
man  became  a  leper  and  was  seen  by  the  commission. 

A  white  man,  aged  thirty -five,  born  in  England,  cohabited  with  a 
colored  woman  who  was  leprous  without  the  fact  being  known.  He 
became  a  leper  and  died  of  the  disease  in  Europe. 

Munro  also  quotes  Schilling  to  the  effect  that  he  could  point  out 
many  examples  of  husbands  and  wives  contracting  the  disease  during 
marriage  "did  shame  j)ermit." 

Rm^ity  of  Contamination  of  Physicians,  Nurses,  and  Others  loho  Care 
for  Lepers.- — The  argument  of  the  Koyal  College  of  Physicians  against 
the  contagiousness  of  leprosy  was  chiefly  based  upon  data  of  this  na- 
ture, viz. ,  "  the  evidence  derived  from  the  experience  of  attendants  in 
leper  asylums  is  especially  conclusive  upon  this  point." 

The  same  argument  might  be  employed  against  the  contagiousness 
of  syphilis,  tuberculosis,  etc.  During  his  long  service  at  the  Bromp- 
ton  Hospital  for  Consumptives  Williams  declares  that  he  has  observed 
only  three  or  four  cases  of  contagion  among  the  personnel  of  the  hos- 
pital. 

In  the  great  establishments  for  consumptives  at  Gorbersdorf,  in 
German}^  which  have  received  twenty-five  thousand  jjatients  within 
forty  years,  the  mortality  among  the  attendants,  who  are  taken  from 
an  outdoor  to  an  indoor  life,  is  very  low  in  spite  of  most  exhausting 
work. 

The  immunity  against  leprosy  is  no  more  remarkable  than  that  ex- 
hibited by  the  attendants  upon  consumptive  patients.  In  general  hos- 
pitals where  tuberculous  i)atients  are  received  without  being  isolated, 
as  well  as  in  special  sanatoria  for  this  class  of  patients,  the  rarity  or  ab- 
sence of  transmission  of  the  disease  is  a  matter  of  common  observation. 


442  MORROW— LEPROSY. 

lu  my  observatiou  of  more  tliau  fifteen  jears  in  the  venereal 
wards  of  the  Charity  Hospital  of  this  city  I  have  known  of  but  two 
jihysiciaus  who  have  contracted  syi)hilis  from  contact  with  patients 
in  this  service.  Within  the  same  period  I  have  been  consulted  by 
twenty  times  that  number  of  medical  men  w^ho  have  contracted  syph- 
ilis in  family  practice,  surgical  and  obstetrical.  It  is  a  noteworthy 
fact  that  specialists  in  venereal  disease  who  are  most  exi:iosed  to  con- 
tact with  syphilis  are  rarely  contaminated,  because  they  recognize 
the  possible  dangers  and  take  greater  jjrecautions  against  infection, 
while  those  engaged  in  family  practice  are  not  impressed  with  a  recog- 
nition of  the  risks  incurred  and  the  necessity  of  great  circumspection 
in  the  examination  of  patients  of  whose  possible  syphilitic  historj- 
and  antecedents  they  know  nothing. 

Neve  has  suggested  the  possibility  of  immunity  to  the  infection  of 
leprosy  being  acquired  by  habituation.  "  We  know  that  a  pathologist 
engaged  in  constant  post-mortem  work  enjoys  a  freedom  from  acci- 
dental blood  poisoning  not  shared  by  those  fresh  to  the  work.  The 
surgeon  who  frequently  attends  cases  of  infectious  disease  appears  to 
become  similarly  protected.  Does  living  in  contact  with  leprosy  ever 
produce  a  like  immunity?" 

Physicians  who  care  for  lepers  in  hospitals  and  asylums  are  quite 
as  liable  to  contract  leprosy  as  others  who  are  equalh'  exposed.  The 
reason  why  they  commonly  escape  contamination  is  because  simple 
measures  of  precaution  and  disinfection  and  the  intelligent  avoidance 
of  intimate  contact  reduce  the  chances  of  contagion  to  a  minimum. 
But  even  with  all  the  precautions  which  may  be  taken  the  exemption 
of  physicians  is  not  nearly  so  complete  as  has  been  pretended.  We 
are  obliged  to  admit  professional  leprosy  as  well  as  professional 
syphilis. 

Vidal  has  reported  the  case  of  a  Braziliau"  doctor  who  attended 

lepers  and  became  himself  a  leper.     Some  years  ago  Dr.  X from 

South  America,  who  had  attended  lepers  in  his  country,  came  under 
my  observation  for  leprosy.  Miss  C ,  of  Ohio,  a  medical  mis- 
sionary, who  attended  on  lepers  in  India,  consulted  me  on  her  return 
to  this  country  and  was  found  to  be  suffering  from  leprosy.  I  have 
information  of  three  physicians  wdio  contracted  leprosy  in  Hawaii. 
"Schilling,  McNamara,  Lander,  Hillebrand,  Kobertson,  Livingston, 
Carter,  Pas(iuier,  and  many  others  have  published  cases  of  attend- 
ants on  lepers  and  even  doctors  themselves  who  have  been  after  a 
time  attacked  by  the  disease"  (Leloir). 

Numerous  cases  are  recorded  of  Sisters  of  Charity  and  nui^es  who 
have  contracted  leprosy  in  caring  for  the  sick  in  asylums  and  hospi- 
tals.    The  proportion  of  the  Kohuas  or  helpers  in  the  leper  settle- 


HEEEDITY  AND  CONTAGION.  443 

ment  of  Molokai  who  become  contaminated  is  from  nine  to  ten  per 
cent. 

As  conspicuous  examples  of  priests  who  have,  in  attending  upon 
lepers,  contracted  the  disease,  may  be  mentioned  Father  Baglioli,  who 
attended  lepers  in  the  Charity  Hospital  of  New  Orleans,  and  remem- 
bers giving  extreme  unction  to  two  of  them,  rubbing  their  hands  with 
oil  during  the  administration  of  the  rites.  In  his  case  the  first  symp- 
tom was  swelling  of  the  mucous  membrane  of  the  nostrils.  The  case 
of  Father  Damien,  which  was  long  cited  as  an  example  of  the  non-con- 
tagiousness of  leprosy,  although  he  finally  succumbed  to  the  disease, 
is  too  well  known  to  require  more  than  mention.  Undoubtedly  the 
proportion  of  attendants  upon  lepers  who  contract  the  disease  is  much 
larger  than  is  generally  supposed.  Prolonged  exemption  does  not 
guarantee  a  continued  immunity. 

A  case  which  has  been  frequently  cited  as  a  proof  of  the  non-conta- 
giousness of  the  disease  was  that  of  the  washerwoman  of  the  Leper 
Hospital  of  Molokai  who  had  washed  the  soiled  clothing  of  the  worst 
patients  for  seventeen  years.  In  addition  she  had  lived  with  two 
leper  husbands  in  succession,  and  yet  she  had  remained  hale,  hearty, 
and  apparently  healthy  during  all  this  period.  Upon  the  occasion  of 
my  first  visit  to  the  leper  settlement  in  1889  I  found  that  this  woman 
was  suffering  from  undoubted  manifestations  of  the  disease. 

Several  years  ago  I  instanced  the  case  of  Mr.  D ,  who  had  lived 

for  nine  years  in  the  leper  settlement  of  Molokai  in  daily  and  inti- 
mate contact  with  lepers — his  principal  work  being  the  dressing  of 
leprous  sores  and  ulcers,  sometimes  attending  to  one  hundred  and 
fifty  a  day — as  a  notable  example  of  immunity  against  contagion. 
Quite  recently  it  has  transpired  that  he,  too,  has  become  a  leper. 

Leprosy  Imported  into  Certain  Countries  does  not  Spread. — Con- 
clusions as  to  the  interpretation  of  this  fact  and  its  bearing  upon  the 
contagiousness  of  leprosy  will  depend  largelj-  upon  the  point  of  view 
from  which  the  question  is  envisaged.  If  the  observer  limits  his  field 
of  examination  and  judgment  to  certain  parts  of  Europe  and  the 
United  States,  he  may  find  little  clinical  evidence  of  the  active  spread 
of  lepros}^  by  contagion.  Observation  shows  that  leprous  germs  in- 
troduced into  these  favored  regions  do  not  take  root  and  spread ;  they 
rarely  survive  the  death  of  the  leper. 

In  New  York,  for  example,  large  numbers  of  lepers  coming  from 
countries  where  leprosy  is  endemic  have  lived  for  years,  many  of 
them  have  been  sent  to  general  hospitals  where  they  have  died,  and 
yet  so  far  as  is  known  no  case  of  indigenous  leprosy  can  be  traced  to 
association  or  contact  with  these  patients.  The  same  experience  has 
been  noted  in  London,  Paris,  and  Berlin,  where  lepers  from  other 


444  MORROW— LEPROSY, 

countries  have  flocked  for  treatment  and  have  been  received  in  the 
general  hospitals  without  special  measures  of  isolation,  and  yet 
no  case  of  leprous  contamination  has  been  traced  to  contact  with 
them. 

If,  however,  the  field  of  observation  be  somewhat  enlarged,  em- 
bracing the  whole  of  Europe  and  the  United  States,  it  will  be  found 
that  wliile  in  certain  regions  the  disease  when  introduced  does  not 
spread,  but  rather  tends  to  die  out  from  natural  causes,  yet  in  other 
regions  leprosy  exhibits  the  unmistakable  characters  of  a  contagious 
disease. 

For  more  than  fiftj^  years  there  has  existed  in  Northern  Europe 
an  active  and  important  centre  of  leprosj^  which  spread  more  or  less 
rapidly  during  a  certain  period  until  it  assumed  epidemic  propor- 
tions, but  which  is  now  fortunately  in  process  of  extinction.  Equally 
conclusive  evidence  may  be  found  in  the  development  of  endemic  foci 
in  Parcente,  Alicante,  and  other  provinces  in  Spain,  and  of  small  is- 
olated epidemics  in  other  parts  of  Europe. 

In  the  United  States  we  find  the  same  apparent  anomalies  or  para- 
doxes of  leprous  contagion.  Thus  one  hundred  and  sixty  Norwe- 
gian leper  immigrants  have  settled  in  the  Scandinavian  colonies  of 
our  Northwestern  States,  and  their  histories  have  been  followed  np, 
yet  there  has  not  been  a  single  case  of  contamination  (with  the  pos- 
sible exception  of  one  case  reported  by  Dr.  Hoegh)  traced  to  contact 
with  these  imported  lepers.  Almost  all  of  them  have  died  and  the 
seeds  of  the  disease  have  perished  with  them. 

If  now  we  turn  our  attention  to  the  more  tropical  region  of  our 
Southern  seaboard,  we  shall  find  that  there  has  been  in  Louisiana  a 
notable  and  alarming  increase  in  leprosj^,  and  that  within  the  past 
twentj'-five  jears  it  has  spread  so  rapidly  as  to  i^rove  a  serious  men- 
ace to  the  public  health.  A  remarkable  feature  of  the  Louisiana  epi- 
demic is  that  the  disease  had  formerly  existed  there  during  colonial 
times,  had  become  jiractically  extinct,  and  after  nearly  a  century  of 
silence  and  repose  has  reawakened  into  activity. 

On  the  other  hand,  if  one  takes  a  broad  and  general  survey  of  lep- 
rosy in  all  ages  and  in  all  countries,  there  is  found  the  most  abundant 
and  conclusive  evidence  that  the  disease,  when  introduced  into  a  com- 
munity or  country  previously  exempt,  always  spreads  when  the  con- 
ditions are  favorable.  The  history  of  leprosy  is  one  continuous 
illustration  of  local  and  general  epidemics  originating  from  the 
incoming  of  foreign  lepers  into  non-infected  countries. 

The  study  of  the  disease  in  small  circumscribed  leprosy  areas  with 
a  fixed  population,  where  the  state  of  health  of  the  different  families 
has  been  known  for  a  long  period,  shows  that  its  development  may  al- 


HEREDITY  AND  CONTAGION.  445 

ways  be  traced  to  the  introduction  of  a  leper,  and  its  spread  is  deter- 
mined altogether  by  conditions  of  promiscuity  and  intimate  contact. 

The  outbreak  of  leprosy  in  a  new  country  or  a  non-infected  race 
can  always  be  traced  to  the  immigration  of  lepers.  The  facts  of  the 
development  and  spread  of  leprosy  in  the  Sandwich  Islands  furnish 
the  most  conclusive  proof  of  its  contagiousness.  Upon  no  other  pos- 
sible ground  can  be  explained  the  remarkablj^  rapid  dissemination  of 
the  disease  which  in  the  space  of  a  single  generation  decimated  the 
native  population  of  these  islands.  It  is  estimated  that  at  the  pres- 
ent day  from  five  to  ten  per  cent,  of  the  entire  native  population  is 
affected  with  the  disease,  while  many  foreigners  coming  from  coun- 
tries w^here  leprosy  is  not  endemic  and  free  from  leprous  antecedents 
have  become  infected.  The  number  of  such  cases  is  already  over  one 
hundred,  exclusive  of  the  Chinese,  Japanese,  Portuguese,  and  South 
Sea  Islanders. 

Practically  we  find  that  in  leprous  countries,  where  the  observer 
has  the  opportunity  of  studying  the  disease  at  close  range  and  in  all 
its  phases,  there  is  little  scepticism  as  to  its  contagiousness,  while 
in  non-leprous  countries,  especially  where  the  observer  bases  his 
judgment  upon  a  superficial  and  limited  observation,  doubt  begins  to 
enter. 

Leprosy  does  not  Comport  Itself  as  a  Contagious  Disease.- — Finally 
there  remains  to  be  considered  the  objection  to  the  doctrine  of  con- 
tagion which  is  based  upon  the  exceeding  variability  of  the  contagious 
power  of  leprosy,  and  the  observation  that  under  certain  conditions 
this  characteristic  is  doubtful  or  fails  altogether,  or,  at  any  rate,  is 
not  exhibited  with  that  uniformity  and  coristancy  which  one  would 
naturally  expect  in  a  communicable  disease. 

It  is  claimed  if  leprosy  is  contracted  always  and  only  from  the 
leper  that,  whenever  the  necessary  conditions — the  presence  of  a  leper 
and  proximity  or  contact  with  healthy  persons — coexist,  infection 
should  take  place.  This  objection,  however,  loses  its  importance 
when  it  is  considered  that  each  infectious  disease  has  a  contagious 
mode  peculiar  to  itself,  dependent  partly  upon  the  life  conditions  of 
the  individual  germ  and  partly  upon  the  favorable  or  counteracting 
qualities  of  the  soil  in  which  it  is  implanted. 

It  would  be  illogical  to  assume  that  the  contagious  mode  of  a 
chronic  infectious  disease,  like  leprosy,  of  long  incubation  and  slug- 
gish evolution  should  conform  in  every  particular  to  that  of  an  acute 
infectious  disease  with  a  short  incubation  in  which  the  phenomena 
succeed  each  other  with  great  rapidity,  like  smallpox,  for  example. 
And  yet  many  physicians  deny  the  contagiousness  of  leprosy  because 
it  cannot  be  demonstrated  that  it  is  contagious  in  the  same  manner 


446  MORROW — LEPROSY. 

or  in  tlie  same  degree  of  intensity  as  smallpox  or  even  sj'pliilis.  It 
may  be  admitted  that  the  evidence  of  contagion  in  these  diseases  is 
more  positive  and  direct  than  in  the  case  of  leprosy.  The  intensity 
of  the  contagious  activity  of  the  two  diseases  mentioned  and  the  re- 
ceptivity of  the  human  organism  are  so  i^ronounced  that  contagion  is 
efifected  almost  invariably  when  the  conditions  of  infectious  or  inocu- 
lative contact  exist. 

If,  however,  we  compare  lepros}^  with  tuberculosis,  we  can  trace 
numerous  analogies  in  their  contagious  modes.  AVe  find  the  same 
apparent  anomalies  and  paradoxes  of  contagion,  due  to  the  variable 
virulence  of  their  respective  germs  under  different  conditions.  The 
contagion  of  tuberculosis  is  not  constant  or  invariable,  but  contingent 
upon  the  constitutional  state  and  individual  resistance  of  the  recipient. 
The  most  intimate  and  prolonged  contact  with  a  consumptive  is  not 
necessarily  followed  by  infection.  Marital  contamination  is  rare  in  tu- 
berculosis. Climate  and  other  conditions  exert  an  inhibitory  influ- 
ence not  only  upon  the  development  of  the  disease,  but  also  upon  its 
contagious  activity.  Tuberculosis  is  contagious  in  certain  regions, 
feebly  or  not  at  all  so  in  others. 

The  contagiousness  of  tuberculosis  has  been  established  not  only 
by  clinical  facts,  but  by  successful  cultures  and  inoculations  of  the 
tubercle  bacillus.  The  bacillus  leprae  has  not  been  successfull}^  cul- 
tivated, and  experimental  inquiry  has  thrown  no  light  upon  its  modes 
of  growth  and  manner  of  reproduction.  But  while  we  are  ignorant  of 
the  exact  conditions  under  which  the  pathogenic  agent  of  lei^rosy  is 
best  able  to  maintain  and  perpetuate  its  existence,  observation  shows 
conclusively  that  the  surroundings  which  man  acquires  in  certain 
localities  are  destructive  of  the  microbes,  while  in  other  localities  the 
conditions  which  surround  man  favor  their  preservation  and  propa- 
gation. 

Van  Dyke  Carter  remarks,  apropos  of  this  aspect  of  the  question, 
that  "  the  direct  communication  of  disease  is  hedged  around  also  by 
modifying  influences  belonging  to  both  giver  and  taker,  and  these  in- 
fluences are  so  i)owerful  and  complex  that  the  event  in  question — con- 
tagion— becomes  to  be  regarded  by  many  as  a  matter  of  doubt." 

Further,  it  may  be  said  that  the  "variable  virulence,"  as  it  has 
been  termed,  of  leprous  contagion  at  different  epochs  and  in  different 
countries  is  no  more  remarkable  than  that  exhibited  by  other  diseases. 
Its  development  and  decline,  its  exacerbations  and  subsidences,  and 
its  resurrection  in  certain  countries  after  long  i^eriods  of  silence  and 
apparent  extinction  are  paralleled  in  the  history  of  other  diseases. 
The  epidemic  of  lepros}^  which  devastated  Europe  during  the  Middle 
Ages  has  its  analogue  in  the  invasion  of  Europe  by  syphilis  at  the 


MODES  OF  INFECTION.  447 

end  of  the  fifteentli  century,  which  broke  out  in  the  form  of  a  wide- 
spread and  malignant  epidemic  and  overran  a  large  part  of  Europe, 
and  which,  after  maintaining  an  excessive  virulence  for  several 
decades,  gradually  lost  its  epidemic  character  and  assumed  the 
milder  type  which  it  exhibits  at  the  present  day.  The  phenomenal 
outbreaks  of  syphilis  in  the  character  of  an  epidemic  or  endemic  in 
Scotland  during  the  seventeenth  century,  in  Norway  and  Sweden, 
and  in  various  parts  of  Europe  during  the  eighteenth  century,  may 
also  be  mentioned  as  illustrating  the  variable  virulence  of  this  dis- 
ease. 

The  epidemic  violence  of  leprosy  when  introduced  in  a  new  coun- 
try where  the  racial  susceptibility  and  habits  of  living  favor  its 
sjjread,  and  which  has  been  so  strikingly  seen  in  the  Sandwich 
Islands,  New  Caledonia,  and  other  modern  centres  of  leprosy,  is  only 
an  illustration  of  the  special  virulence  and  malignancy  which  any 
infectious  disease  assumes  when  transplanted  into  a  favorable  soil. 
Other  illustrations  of  this  are  seen  in  the  ravages  of  syphilis  intro- 
duced into  Hawaii  by  Captain  Cook's  men  in  1779,  of  measles  in 
1849,  and  of  smallpox  in  1853,  and  the  pestilential  violence  of  smallpox 
in  Iceland  in  1707,  which  killed  eighteen  thousand  persons.  The  epi- 
demic of  measles  in  1846  destroyed  not  only  a  large  proportion  of  the 
inhabitants  of  Iceland,  but  killed  almost  all  the  lepers.  Numerous 
other  examples  might  be  cited  to  show  that  the  inequalities  and  ir- 
regularities of  contagion  by  no  means  particularize  leprosy,  but  are 
exhibited  by  all  infectious  diseases. 

Modes  of  Infection. 

Although  the  pathogenic  agent  of  leprosy  has  been  identified,  and 
its  constant  presence  in  the  lesions  it  causes  demonstrated  beyond  all 
possibility  of  doubt,  there  are  many  points  connected  with  the  modes 
of  its  entrance  into  the  system  and  the  conditions  which  favor  its 
growth  and  i^ropagation  which  are  yet  undetermined.  It  is  very 
probable  that  the  modes  of  leprous  contagion  are  many.  While  we 
must  recognize  that  the  knowledge  of  the  possible  numerous  and 
varied  processes  by  which  leprous  contaminations  take  place  pos- 
sesses the  highest  interest  and  importance  from  a  prophylactic  point 
of  view,  yet  it  must  be  confessed  that  the  precise  manner  in  which 
the  leprous  virus  is  transferred  from  one  individual  to  another  is 
unknown. 

The  bacillus  leprae  must  be  transmitted  either  directly  or  medi- 
ately from  individual  to  individual.  It  has  been  suggested  that  it 
may  run  through  a  stage  of  intermediate  life  (spore  condition)  which 


448  MORROW — LEPROSY. 

we  are  at  present  unable  to  detect,  either  on  account  of  the  minuteness 
of  the  spores  or  on  account  of  the  imperfection  of  our  staining  meth- 
ods ;  which  may  be  present  in  the  soil,  water,  or  food,  but  can  get 
into  them  only  from  diseased  tissues  of  the  leper  (Arning) . 

It  is  possible  that  the  contagious  activity  of  leprosy,  like  that  of 
syphilis  and  other  infectious  diseases,  may  undergo  certain  modifi- 
cations during  the  evolution  of  the  disease  and  be  inoculable  only  at 
certain  periods. 

Whether  leprosj'  may  be  propagated  by  inoculative  contact, 
through  sexual  intercourse,  through  the  skin  by  accidental  wounds 
and  lesions  of  continuity ;  whether  it  lasbj  be  conveyed  by  the  process 
of  vaccination,  by  bites  or  stings  of  flies,  mosquitoes,  and  other 
insects ;  whether  its  virulent  principle  may  attach  to  the  soil,  water, 
and  food  and  be  introduced  as  are  the  germs  of  cholera  by  imbibition, 
or  by  inhalation  of  the  virus  contained  in  the  sputum,  disseminated 
in  the  form  of  dust  through  the  air,  as  in  tuberculosis ;  or  whether 
objects  surrounding  the  leper  upon  which  the  virus  has  been  acci- 
dently  deposited  may  serve  as  a  medium  of  transference  from  one  per- 
son to  another,  are  points  concerning  which  there  is  great  diversity 
of  opinion.  The  absence  of  any  definite  primary  lesion  upon  the 
outer  surface  of  the  body  which  marks  the  point  of  entrance  of  the 
virus  into  the  system  tends  to  still  further  complicate  the  difficulties 
in  solving  the  pathogenic  problem. 

Sexual  Intercourse. — Although  I  formerly  attached  considerable 
significance  to  this  possible  mode  of  contagion,  I  now  believe  it  plays 
a  very  inappreciable  role  in  conveying  the  germs  of  lepros}'.  The 
thousand  and  one  intimacies  which  attach  to  the  married  relation 
afford  abundant  facilities  for  infection  quite  independent  of  sexual 
contact.  It  is  quite  conceivable,  however,  that  if  the  sexual  organs 
are  the  seat  of  leprous  lesions,  as  is  not  infrequently  the  case  in  the 
tubercular  form,  the  abrasions  or  solutions  of  continuity  of  the  mu- 
cous membranes  which  often  occur  in  coitus  constitute  favorable  fora- 
mina contagiosa. 

In  some  leprous  countries  this  mode  of  contagion  is  generally  ac- 
cepted 1)3'  the  lait}"-  and  also  by  many  of  the  i^rofession  as  the  almost 
exclusive  mode  of  propagating  the  disease,  the  belief  being  based  upon 
the  observation  that  if  the  husband  or  wife  is  leprous  the  healthy 
partner  often  becomes  contaminated,  and  that  healthy  persons  having 
illicit  relations  with  lepers  frequently  contract  the  disease.  This 
opinion  is  so  universal  and  deeplj^  rooted  in  the  Sandwich  Islands 
that  accusations  of  immorality  M-ere  brought  against  Father  Damien, 
based  solely  on  the  ground  that  his  disease  could  have  been  contracted 
only  through  illicit  intercourse.     Two  of  my  patients  from  Honolulu 


MODES  OF  INFECTION.  449 

have  assured  me  that  their  principal  dread  of  having  the  real  nature 
of  their  disease  known  was  that  it  would  carry  to  the  minds  of  their 
friends  a  conviction  of  their  immorality. 

Kissing. — It  is  well  known  that  kissing  represents  one  of  the  most 
common  modes  of  syphilitic  contagion;  it  is  very  probable  that 
leprous  infection  may  take  place  in  the  same  way.  In  tubercular 
cases,  as  is  well  known,  the  buccal  cavity  swarms  with  bacilli  which 
are  present  not  only  in  the  leprous  lesions,  but  also  in  the  saliva, 
which  is  mixed  with  the  secretions  of  these  lesions.  Any  break  in 
the  continuity  of  the  delicate  epithelial  covering  of  the  lips  would 
render  inoculation  possible. 

It  has  been  suggested  that  the  custom  which  exists  in  Iceland  of 
kissing  all  persons  present  when  entering  a  room  may  be  a  fruitful 
source  of  contagion.  Dr.  Ehlers  has  seen  lepers  thus  kissed  by  well 
persons.  On  account  of  this  custom  he  is  opposed  to  the  isolation  of 
lepers  in  their  own  homes,  as  practised  in  Norway. 

The  custom  of  salutation,  which  is  common  among  the  Hawaiians, 
of  kissing  and  rubbing  their  noses  together  when  they  meet  has  been 
suggested  as  one  of  the  means  of  spreading  leprosy^  in  the  Sandwich 
Islands. 

Wounds  and  Ah^asions  of  the  Integument. — It  is  a  question  whether 
the  virulent  principle  of  leprosy  may  find  entrance  to  the  organism 
through  cracks,  fissures,  or  abrasions  in  the  integument.  The  fact 
that  the  first  appearance  of  the  leprous  manifestations  is  commonly 
on  the  exposed  parts,  the  face  and  extremities,  and  that  in  countries 
where  the  natives  go  barefoot  the  plantar  ulcer  is  often  the  earliest 
lesion,  lends  support  to  this  view.  It  is  worthy  of  note  that  in  coun- 
tries where  leprosy  is  endemic,  the  opinion  generally  prevails  that  the 
disease  is  often  spread  by  accidental  inoculation  through  contact  of 
broken  surfaces.  Since  the  demonstration  by  Babes  of  the  passage 
of  lepra  bacilli  along  the  hair  follicles  and  through  the  intact  skin 
and  that  the  skin  of  lepers  in  tubercular  cases  may  be  coated  with 
bacilli  coming  through  the  hair  follicles,  the  theory  of  inoculation  by 
contact  with  a  leper's  body  is  quite  plausible. 

Nursing. — Since  the  milk  in  women  suffering  from  tubercular 
leprosy  contains  the  parasite,  Babes  has  expressed  his  belief  that 
leprosy  may  be  conveyed  in  the  process  of  suckling.  He  reports  a 
case  in  which  a  lesion  on  the  cheek  was  observed  as  the  first  evi- 
dence of  the  disease  in  a  child  nursed  by  a  leprous  woman.  In 
certain  leprous  countries,  especially  in  India,  the  opinion  prevails 
that  the  germs  of  leprosy  may  be  conveyed  in  the  act  of  nursing. 
Sir  Konald  Martin  states  that  the  dangers  to  Europeans  of  contract- 
ing leprosy  in  India  arise  chiefly  through  nursing  and  vaccination. 
Vol.  XVIII.— 29 


450  MORROW — LEPROSY. 

Other  observers  also  speak  of  the  probability  of  the  infection  having 
been  conveyed  in  this  way. 

Leprosy  Communicated  by  the  Bite  of  a  Leper. — If  leprosy  may  be 
inoculated  through  the  skin,  the  possibility  of  this  mode  of  infection 
is  evident.     I  find  in  my  notes  taken  in  Molokai  the  following : 

John  G ,  on  July  4th,  1877,  was  bitten  by  a  leper  in  an  ad- 
vanced stage,  who  died  of  the  disease  in  1883.  The  bite  was  on  the 
middle  finger  of  the  right  hand  and  cut  through  nearh'  to  the  bone. 
The  hand  and  forearm  at  once  became  swollen,  and  were  lame  and 
})ainf ul,  with  shooting  pains,  for  about  a  week.  The  wound  gradually 
healed  and  the  arm  l3ecame  as  usual.  Some  years  later  he  noticed 
that  the  right  hand  assumed  a  bluish  appearance  occasionally.  Later 
on  the  other  hand  became  similarly  affected.  Soon  afterwards  a 
bluish  spot  appeared  on  the  right  hand,  which  still  persists,  although 
it  has  now  become  yellow.  Earl}-  in  1885  he  was  declared  to  be  a 
leper  and  sent  to  the  leper  settlement.  He  firmly  believes  from  all 
the  circumstances  that  the  disease  has  its  origin  in  him  from  the  bite 
of  a  native  leper. 

Vaccination. — The  question  whether  leprosy  may  be  conveyed  to  a 
healthy  person  in  the  process  of  vaccination  possesses  at  the  present 
time  rather  a  retrospective  than  an  actual  interest.  In  many  leprous 
countries  the  methods  and  appliances  of  modern  medicine  are  em- 
ployed, and  the  use  of  humanized  has  been  supplanted  by  that  of 
bovine  virus.  In  some  countries,  however,  even  at  the  present  day, 
where  bo\dne  virus  cannot  readily  be  procured,  and  especiall}-  when 
a  smallpox  epidemic  threatens,  arm-to-arni  vaccination  is  still  prac- 
tised. It  must  be  admitted  that  if  leprosy  be  inoculable,  arm-to-arm 
vaccination  in  leprous  countries  constitutes  a  direct  and  most  effec- 
tive method  of  conveying  the  germs. 

Even  when  bovine  virus  is  used,  if  a  number  of  individuals,  one 
of  whom  ma}'  be  leprous,  are  inoculated  in  succession,  the  possibility 
of  conveying  the  germs  from  one  person  to  another,  b}'  not  thoroughly 
disinfecting  the  lancet  after  each  vaccination,  must  be  borne  in  mind. 

The  clinical  evidence  that  vaccination  may  be  the  means  of  propa- 
gating leprosy  rests  upon  the  observation  of  individual  cases  in  which, 
for  example,  a  single  member  of  a  family  has  been  vaccinated  and 
afterwards  develops  leprosy  while  the  other  unvaccinated  members 
escape,  and  upon  the  rapid  spread  of  leprosy  in  certain  countries  after 
a  general  vaccination.  Of  course,  it  is  to  be  remembered  that  in 
leprous  countries  there  must  exist  many  opportunities  for  infection 
in  other  ways  that  may  escape  observation,  and  the  proof  is  rather 
presumptive  than  positive.  It  is  also  claimed  that  as  children,  who 
are  commonly  exempt  from  leprous  manifestations,  are  usually 
emijloyed  as  vaccinifers,  the  danger  is  reduced  to  a  minimum.     It 


MODES  OF  INFECTION.  451 

should  not  be  forgotten,  however,  that  children  may  have  the  disease 
in  a  latent  or  undeveloped  form,  and  the  question  then  arises  whether 
the  disease  is  inoculable  in  its  latent  stage  or  only  in  a  subsequent 
period  in  the  evolution  of  the  disease. 

The  most  noteworthy  individual  examples  of  presumed  inocula- 
tion by  vaccination  are  two  cases  reported  by  Professor  Gardiner,  of 
Glasgow,  and  two  cases  of  Dr.  Daubler,  of  Eobben  Island. 

Professor  Gardiner  reports  that  Dr.  J.  C ,  a  resident  of  a  Brit- 
ish colony,  vaccinated  his  own  son  with  the  virus  taken  from  a  child 
X^resumably  healthy,  but  who  afterwards  developed  leprosy ;  and  from 
his  own  child  he  vaccinated  the  son  of  a  Scotch  ship  captain  trading 
between  Scotland  and  the  colony.  By  an  extraordinary  coincidence 
Professor  Gardiner  had  occasion  afterwards  to  see  both  children,  the 
son  of  the  medical  man  and  the  son  of  the  ship  captain,  in  Scotland, 
both  being  affected  with  tubercular  leprosy.  In  both  -  of  these  cases 
the  proof  of  leprosy  having  been  conveyed  by  vaccination  is  pre- 
sumptive, as  the  child  of  the  doctor  may  have  acquired  the  disease 
independent!}^  of  the  vaccination.  In  the  case  of  the  other  child,  who 
visited  the  colony  only  temporarily,  the  chances  of  accidental  con- 
tamination in  other  ways  were  much  less,  and  the  evidence  in  favor  of 
vaccination  was  stronger. 

The  first  of  Dr.  Daubler' s  cases  was  that  of  a  woman  who  was 
quite  healthy  until  vaccinated  in  1885.  She  had  never  in  her  knowl- 
edge come  in  contact  with  leprosy.  About  a  j^ear  after  vaccination  a 
large  livid  patch  began  to  apxjear  around  the  vaccination  mark.  A 
few  months  later  a  creeping  sensation  on  both  sides  of  the  face  was 
noticed,  and  soon  afterwards  the  face  began  to  swell,  and  she  de- 
veloped a  tubercular  condition  of  both  sides  of  the  face  and  ears, 
with  loss  of  the  eyebrows  and  other  evictences  of  tubercular  leprosy. 

The  other  case  was  that  of  a  girl  fifteen  years  old,  who  was  quite 
healthy  until  she  was  revaccinated  in  1885.  She  had  never  seen  any 
one  with  leprosy  to  her  knowledge.  The  same  local  ai^pearances  fol- 
lowed on  the  arms  as  those  described  in  the  previous  case,  and  they 
were  followed  later  by  maculae  of  the  cheeks  and  leprous  tubercles 
on  the  forehead.  Investigation  showed  that  the  person  from  whom  the 
lymph  was  taken  died  of  tubercular  leprosy. 

Dr.  Hillis  reports  a  case  of  a  Portuguese,  born  in  Demerara,  aged 
twenty,  the  son  of  healthy  parents,  and  his  sister,  aged  eighteen,  who 
were  the  subjects  of  tubercular  leprosy.  They  had  both  been  vacci- 
nated with  lymph  obtained  from  a  Portuguese  family  known  to  be 
affected  with  tubercular  leprosy.  They  were  the  only  members  of 
the  family  vaccinated  with  this  lymph.  Three  sisters  and  one  brother 
were  perfectly  healthy. 


452  MORROW — LEPROSY. 

Mr.  B ,  an  intelligent  resident  of  Maui,  narrated  to  me  the  fol- 
lowing case  coming  under  his  personal  observation :  A  family  on  the 
island  consisted  of  the  father,  mother,  and  five  children.  The  older 
members  of  the  family  having  been  vaccinated  previous  to  coming 
there,  only  the  youngest  child  was  vaccinated  with  humanized  lymph. 
This  child  alone  of  the  entire  family  became  a  leper. 

In  the  Sandwich  Islands  the  opinion  generally  prevails  that  leprosy 
may  be  inoculated  in  the  process  of  vaccination.  This  opinion  was 
based  upon  the  observed  fact  that  there  was  a  notable  increase  in  the 
number  of  cases  of  leprosy  after  a  general  vaccination  immediately 
succeeding  the  smallpox  epidemics  of  1852,  1868,  and  1872,  and  that 
numerous  leprous  centres  developed  in  various  parts  of  the  islands 
where  the  disease  had  previously  been  unknown.  In  many  places 
vaccination  was  performed  by  careless  and  unskilful  persons.  Hu- 
manized virus  was  used,  and  it  is  presumed  that  careful  discrimination 
was  not  always  made  between  lepers  and  healthy  persons  as  vacci- 
nifers. 

Dr.  Arning  says :  "  There  can  be  no  doubt  as  regards  the  ajm- 
chronousness  of  the  diffusion  of  leprosy  and  the  introduction  of  vac- 
cination into  the  Hawaiian  Islands.  I  am  able  to  state,  having  excel- 
lent authority  for  so  doing,  though  unfortunately  no  statistics,  that  a 
very  remarkable  accumulation  of  fresh  leprosy  cases  took  place  in 
1871  and  1872,  at  a  place  called  Lahaina  on  the  island  of  Maui.  This 
happened  about  a  year  after  a  universal  arm-to-arm  vaccination  which 
had  been  most  carelessly  performed.  From  fifty  to  sixty  cases  oc- 
curred suddenly  in  this  locality,  which  up  to  this  time  had  been  com- 
paratively free  from  the  disease."  Impey,  medical  superintendent  of 
the  leper  settlement  at  Eobben  Island,  said :  "  I  wish  to  draw  atten- 
tion to  one  very  serious  matter  in  respect  to  the  spread  of  leprosy. 
It  is  contagious  and  can  be  communicated  from  one  person  to  another 
by  inoculation.  In  South  Africa  the  reprehensible  practice  of  arm-to- 
arm  vaccination  is  carried  on  to  an  enormous  degree.  Some  means 
should  be  employed  to  stop  the  dangerous  practice  of  vaccinating 
with  humanized  lymph, "  etc. 

Arning  has  demonstrated  the  presence  of  bacilli  in  the  crusts  of 
vaccine  pustules  in  tubercular  lepers.  Dr.  A.  Mitra,  chief  medical 
officer  of  Cashmir,  says :  "  I  have  on  three  occasions  searched  for 
bacilli,  and  in  one  instance  I  found  them  in  lymph  from  a  vaccinated 
leper." 

Dr.  A.  Brown,  in  a  pamphlet  on  "  Leprosy  in  its  Contagio-syphi- 
litic  and  Vaccinal  Aspects,"  says:  " The  unanimity  and  persistency 
with  which  vaccination,  in  markedly'  leprous  countries,  is  charged 
with  propagating  and  disseminating  the  malady,  the  well-confirmed 


MODES   OF  ESTFECTION.  453 

coincidence  of  leprous  centres  with  vaccination  centi'es,  and  the  dis- 
covery of  the  specific  bacilli  in  those  leprously  vaccinated  ought  to 
satisfy  all  who  are  capable  of  reading  evidence  or  of  rational  reflection 
that  controversy  on  the  questions  must  and  will  ere  long  be  silenced." 

Tebbs,  in  a  recent  work,  endeavors  to  demonstrate  that  the  remark- 
able recrudescence  of  leprosy-  in  various  countries  at  the  present  day 
is  chiefly  due  to  inoculation  through  the  process  of  vaccination. 
Wliile  such  a  sweeping  statement  cannot  be  unqualifiedly  accepted,  it 
must  be  admitted  that  the  author  has  collected  a  vast  number  of  ob- 
servations which  give  plausibility  to  his  views.  It  is,  of  course,  only 
in  countries  where  humanized  virus  is  employed  that  this  possi- 
ble danger  exists,  which  emphasizes  the  necessity  of  controlling  the 
source  of  the  vaccine  matter. 

Inoculation  hy  Insects.— The  theory  that  certain  diseases  are  con- 
veyed by  insects  rests  on  a  fu-m  foundation.  The  investigations  of 
Manson  and  Eoss  on  the  intimate  relations  existing  between  mos- 
quitos  and  the  dissemination  of  malaria  have  given  a  new  interest  to 
this  question.  Again,  in  many  countries  where  leprosy  is  endemic 
there  is  a  more  or  less  general  impression  that  the  germs  of  the  dis- 
ease may  be  transported  from  the  leper  by  flies  and  mosquitos  and 
inoculated  into  healthy  i:>ersons.  Although  the  communicabilitj^  of 
leprosy  in  this  way  has  not  been  demonstrated,  it  is  quite  credible 
and  worthy  of  scientific  investigation. 

It  is  interesting  to  note  that  the  plague  of  mosquitos  and  the 
plague  of  leprosy  appeared  simultaneously  in  the  Hawaiian  Islands. 
Mosquitos  which  had  previously  been  quite  unknown  there  were  im- 
ported, probably  from  China,  towards  the  end  of  1840  (Arning). 

The  same  observer  states  that  he  has  frequently  examined  bacteri- 
ospically  mosquitos  engorged  with  blood,  found  inside  the  mosquito 
netting  of  beds  conttiining  cases  of  severe  cutaneous  leprosy,  without 
discovering  traces  of  bacilli  either  in  or  upon  them.  Others  have 
examined  flies  and  mosquitos  which  came  in  contact  with  leprous 
patients  and  pustules  on  the  bodies  of  lepers,  but  the  results  have 
always  been  negative  until  recently  Alvarez  claims  to  have  discovered 
the  presence  of  bacilli  in  mosquitos  engorged  with  the  blood  of 
lepers. 

That  mosquitos  and  flies  are  common  carriers  of  leprous  contagion 
would  seem  improbable,  since  if  this  were  the  case,  the  transference 
of  the  disease  from  lepers  to  healthy  persons,  in  countries  where 
these  pests  abound,  would  be  much  more  common. 

Ashmead,  in  speaking  of  the  agency  of  mosquitos  in  conveying 
the  bacilli  of  leprosy,  does  not  limit  his  theory  to  the  idea  that  the 
virus  is  conveyed  by  the  insect's  haustellum.     He  thinks  that  eating 


454  MORROW — LEPROSY. 

fish,  sucli  as  carp,  which  are  fed  on  the  eggs  of  mosquitos,  maj'  be 
tlie  cause. 

Dr.  Hutchinson,  in  reviewing  this  theorj^  of  the  etiology  of  the 
disease,  states  "  that  leprosy  prevails  on  the  seaboard  where  neither 
nioscjuitos  nor  mosquito-eating  fish  are  found."  It  is  probable  that 
there  are  manj^  places  where  leprosy  prevails  and  where  nios(iuitos 
are  unknown.  If  the  poison  were  conveyed  by  insects,  we  should 
l)robabl3^  have  some  localities  where  every  person,  residents  and  vis- 
itors all  alike,  would  suffer,  just  as  there  are  i^laces  where  no  one 
escapes  malaria. 

Inhalation. — While  this  mode  of  infection  rests  upon  presumptive 
rather  than  positive  evidence,  recent  advances  in  our  knowledge  of 
leprosy  would  seem  to  indicate  that  it  plays  an  active,  if  not  the  most 
prominent,  part  in  the  propagation  of  the  disease.  It  is  i)ossible  that 
the  germs  are  contained  in  the  expired  air,  when  the  aerial  passages 
are  the  seat  of  leprous  deposits,  and  are  projected  in  the  process  of 
sneezing  and  coughing.  Just  as  in  the  case  of  tuberculosis,  the  spu- 
tum of  leprous  patients,  which  has  been  shown  to  be  loaded  with 
bacilli,  may,  I  believe,  when  scattered  through  the  air  with  particles 
of  dust,  serve  as  a  means  of  transporting  the  contagion. 

It  is  to  be  observed  that  the  theory'  of  contagion  through  the  re- 
spiratory passages  was  held  by  the  ancients.  It  was  forbidden  to 
lepers  in  walking  to  go  between  the  wind  and  those  passing  by,  lest 
they  should  be  contaminated  by  the  leprous  emanations.  In  the  Mid- 
dle Ages  the  leper  "  was  especially  prohibited  from  walking  in  narrow 
paths  or  from  answering  those  who  spoke  to  him  in  the  roads  and 
streets,  unless  in  a  whisper,  lest  they  be  annoyed  hy  his  pestilent 
breath  and  with  the  infectious  odor  which  exhaled  from  his  body." 

Imhibifio)/. — Liveing  believes  that  leprosy  ma}^  be  propagated  by 
the  imbibition  of  the  secretions  of  those  affected,  much  in  the  same 
way,  though  not  in  the  same  degree,  as  typhoid  fever  and  cholera  are 
propagated ;  but  as  leprosy  is  developed  slowly  there  is  far  greater 
difficulty  in  tracing  it  home  to  its  true  source. 

Fish  Theory. — The  fact  that  leprosy  occurs  more  frequently  along 
maritime  coasts,  where  the  inhabitants  employ  fish  as  their  main 
article  of  diet,  led  doubtless  to  the  popular  tradition  that  leprosy 
was  caused  by  salted  or  rotten  fish. 

Mr.  Jonathan  Hutchinson,  who  is  the  strongest  supporter  of  the 
fish  hypothesis  at  the  present  day,  thinks  fish  may  cause  leprosy  in 
one  of  two  ways — either  there  is  direct  introduction  of  bacilli  into  the 
stomach  or  some  element  of  fish  food  rouses  into  activit}'  the  bacilli 
which  exist  in  the  tissues.  The  hypothesis  that  fish  serves  an  in- 
termediary host  function  for  the  bacilli  is  improbable  from  the  fact 


MODES   OF  INFECTION.  455 

that  the  bacillus  has  never  been  found  in  fish  caught  in  epidemic 
areas,  although  frequent  examinations  have  been  made.  The  fallacy 
of  the  fish  theory  is  proved  by  the  fact  that  leprosy  occurs  among 
people  who  have  never  tasted  fish,  either  because  it  was  not  obtain- 
able or  because  its  use  was  forbidden  by  their  caste  or  religion. 

Dr.  Tholozan,  of  Persia,  states  that  while  there  is  a  great  deal  of 
leprosy  in  Kurdistan,  there  are  no  large  rivers  there,  and  he  is  sure 
that  the  inhabitants  never  eat  any  fish.  In  Teheran,  where  leprosy 
does  not  prevail  to  any  extent,  salt  fish  is  the  staple  article  of  food. 

A  view  of  the  fish  hypothesis,  differing  radically  from  that  of 
Hutchinson,  is  taken  by  Neve,  who  believes  that  the  lepra  bacillus 
may  find  conditions  favorable  to  its  germination  among  the  consider- 
able number  of  organisms  generated  by  putrefying  fish,  hence  serv- 
ing as  a  culture  medium  as  well  as  a  means  of  transport.  Almost 
every  article  of  food  has  been  in  turn  incriminated  as  the  etiologi- 
cal factor,  as  salted  meat,  especially  pork,  vegetables,  milk,  etc. 
Forster  has  shown  that  various  bacilli  may  retain  their  vitality  in 
salt  meat.     Milk  also  is  especially  liable  to  different  forms  of  infection. 

The  herdsmen  of  Cashmere  never  eat  fish,  but  consume  large  quan- 
tities of  milk  (twelve  pounds  of  curds  in  twenty-four  hours).  This 
milk,  it  is  claimed,  could  easily  serve  as  a  transporting  medium  for 
the  bacilli  as  well  as  salted  meat  or  any  kind  of  impure  food  or  water. 

Hicks  and  Blanc  believe  that  the  influence  of  diet  is  limited  to 
preparing  a  defective  and  inflammatory  condition  of  the  intestine  for 
the  reception  of  the  bacilli,  and  in  the  study  of  the  transmission  of 
lejjrosy  it  cannot  be  a  question  of  the  particular  kind  of  food,  but  only 
if  the  characteristic  bacillus  is  present.  If  food  contains  the  bacilli, 
they  must  have  been  derived  from  the  diseased  tissues  of  the  leper. 
I  believe  that  the  bacilli  may  be  deposited  on  vegetables,  fruits,  and 
other  articles  of  food  handled  by  lepers  and  in  this  way  carry  the  con- 
tagion. We  can  also  understand  that  certain  foods  may  so  modify 
the  constitution  of  the  tissues  that  they  afford  a  more  suitable  soil 
for  the  growth  of  the  bacillus  which  has  been  introduced  into  them. 

31ediate  Infection. — It  is  probable  that  infection  may  take  place 
by  means  of  clothing  or  objects  used  by  the  leper  or  through  the 
intermediary  of  food,  drink,  pipes,  cups,  or  other  objects  upon  which 
the  virus  may  be  deposited. 

Many  authorities  believe  in  the  probability  of  this  mode  of  trans- 
ferring the  virus,  and  instances  are  cited  which  would  seem  to  prove 
the  probability  of  infection  occurring  in  this  way.  The  popular 
superstition  of  the  danger  of  handling  tools  or  other  articles  which 
have  been  used  by  lepers  doubtless  has  some  basis  in  fact. 

The  case  reported  by  Hawtrey,  of  an  Irishman  who  had  never 


456  MORROW — LEPROSY. 

beeu  out  of  his  native  country  except  for  a  short  voyage  to  England, 
and  who  contracted  the  disease  by  wearing  the  clothes  or  sleeping 
in  the  bed  of  his  deceased  leper  brother,  who  had  become  a  leper 
in  India ;  the  case  of  a  patient  who  came  into  the  Leper  Hospital  in 
Norway  with  a  history  of  no  leprosy  in  his  family  comprising  twelve 
brothers  and  sisters,  but  who  seven  years  previously  had  bought  a 
coat  which  had  belonged  to  a  deceased  leper  and  which  he  wore  daily ; 
and  numerous  others  of  like  tenor  scattered  through  literature  would 
indicate  that  the  disease  ma,y  be  conveyed  in  this  manner. 

The  wearing  of  the  boots  or  shoes  of  a  leper,  it  is  said,  may  be 
the  means  of  conveying  the  contagion.  In  India  leprosy  is  believed 
to  be  propagated  by  bathing  in  the  reservoirs  which  have  become 
polluted  by  lepers.  Numerous  cases  are  reported  of  infection  of 
laundresses  who  washed  the  soiled  linen  or  bedding  of  lepers  and 
who  were  never  brought  into  close  personal  contact  with  lepers,  which 
is  a  fact  worthy  of  note. 

The  recent  unsuccessful  attempts  of  the  health  authorities  of  Hon- 
olulu to  stamp  out  the  disease  by  the  absolute  segregation  of  every 
person  found  to  be  affected  with  leprosy  is  said  to  be  largely  due  to 
the  fact  that  the  clothing  and  belongings  of  lepers  who  are  transported 
to  Molokai  are  utilized  by  the  famil^^  and  friends  of  the  leper.  Many 
of  the  government  physicians  have  called  attention  to  this  possible 
source  of  danger  in  perpetuating  the  disease. 

Le  Blond  says :  "  There  should  be  rigid  laws  in  reference  to  the 
distribution  of  the  effects  of  lepers.  A  native  has  no  scruple  in  wear- 
ing the  cast-off  coat  of  his  exiled  brother  or  sleeping  in  his  unclean 
bed." 

Lindley  says:  "There  are  many  things  which  could  be  done 
that  would  go  far  to  lessening  the  dangers  of  contagion.  In  almost 
all  cases  where  lepers  are  sent  away  their  effects,  such  as  mats, 
clothing,  etc.,  are  given  to  grieving  friends  and  relatives  left  behind. 
These,  of  course,  are  great  sources  of  contagion." 

Besnier  believes  that  the  leper  can  soil  with  his  pathological  ex- 
cretions the  ground,  his  garments,  bedding,  linen,  dressings,  and  the 
walls,  and  that  the  dust  of  his  room  may  be  a  source  of  leprous  con- 
tamination. 

In  this  connection  it  will  be  of  great  interest  and  value  to  give  the 
most  recent  views  of  the  leprologists  of  all  countries,  which  were  pre- 
sented to  the  Berlin  Leprosy  Congress,  upon  the  modes  of  the  trans- 
mission of  the  bacillus  leprre. 

Sticker  makes  the  sweeping  statement  that  in  about  ninety-six  per 
cent,  of  all  cases  the  primary  focus  of  the  disease  is  in  the  nasal  cham- 
bers and  that  leprous  contamination  is  from  nose  to  nose. 


MODES  OF  ESTFECTION.  457 

Lassar  suggests  tiiat  since  lupus  is  primarily  developed  on  the  lips 
and  nose  of  children  by  picking  or  scratching  these  parts,  leprosy 
may  be  communicated  in  the  same  way,  and  recommends  that  chil- 
dren in  leprous  countries  should  be  taught  to  avoid  this  habit. 

Ai"ning  does  not  believe  that  the  primary  manifestation  is  in  all 
instances  intranasal.  In  many  cases  he  had  carefully  examined  the 
nose  and  found  nothing.  He  had  seen  in  one  case  at  least  the  pri- 
mary lesion  on  the  skin.  In  countries  where  people  go  barefoot  there 
are  more  cases  in  which  leprosy  begins  on  the  foot. 

Geill  believes  that  the  leper  contaminates  the  soil  and  that  it 
is  through  the  soil  that  healthy  individuals  are  most  often  infected. 
He  thinks  that  in  order  to  transmit  the  virulent  bacilli  certain  quali- 
ties of  soil,  not  found  everywhere,  are  essential. 

In  India  and  Tonquin,  where  the  natives  go  barefoot,  the  dis- 
ease appears  first  on  the  feet  in  more  than  fifty  per  cent,  of  the 
cases. 

Hellat  (Kiga),  while  accepting  the  theory  that  the  bacilli  may  be 
inhaled,  thinks  that  there  is  no  proof  that  the  vital  power  of  the  nasal 
mucous  membranes,  which  is  efficacious  enough  to  expel  and  destroy 
numerous  other  bacilli,  is  powerless  against  the  lepra  bacilli.  He 
thinks  that  the  skin  may  be  the  seat  of  entrance  and  refers  to  numer- 
ous cases  in  which  leprosy  has  been  transmitted  by  boots. 

Ehlers  believes  that  the  initial  lesion  of  leprosy  varies  according 
to  the  geographical  latitude  and  conditions  of  life.  In  Iceland  the 
first  manifestations  appear  upon  the  face  and  hands.  As  is  well 
known  to  be  the  case  in  syphilis,  there  is  no  place  that  may  not  be 
the  point  of  entry  for  leprosy.  In  this  country  the  respiratory 
passages  are  the  first  affected. 

Babes  says  the  most  important  question  is,  whether  we  can  con- 
sider the  first  visible  manifestation  as  the  place  of  entrance  of  the 
infection.  He  indicates  the  possibility  of  infection  through  milk  in 
which  he  has  found  bacilli,  and  cites  a  case  of  Kalindero  in  which  a 
child  nursed  by  a  mother  with  mixed  leprosy  developed  an  isolated 
leproma  on  the  cheek, 

Petrini  thinks  it  possible  that  the  bacilli  may  be  introduced  into 
the  organism  by  means  of  certain  aliments,  as  we  see  many  cases  of 
leprosy  in  families  where  the  food  is  in  common. 

Abrahams  believes  that  the  lepra  bacilli  may  enter  into  the  human 
system  in  as  many  ways  as  may  those  of  tuberculosis. 

Alvarez  says  that  in  Hawaii  one  may  incriminate  as  a  means  of 
transmitting  leprosy  the  common  use  of  the  pipe,  which  is  passed 
from  mouth  to  mouth  in  families. 

Jeanselme  refers  to  his  investigations  which  would  indicate  the 


458  MORROW— LEPROSY. 

nose  as  the  principal  point  of  entry,  as  well  as  the  most  virulent 
source  of  contagion, 

Hallopeau  oj^poses  the  view  of  infection  through  the  nasal  mucous 
membrane  and  also  by  sexual  transmission.  If  invasion  through  the 
pituitary  membrane  was  habitual  or  even  possible  by  atmospheric 
dust,  we  cannot  comprehend  why  our  patients  living  for  years  in  a 
medium  charged  with  infected  dust  should  remain  unaffected.  He  is 
inclined  to  accept  the  hypothesis  of  infection  through  linen,  clothing, 
stings  of  mosquitoes,  etc. 

Neisser  thinks  that  the  contagion  may  be  received  by  respired  air, 
and  the  infection  of  the  skin,  mucous  membrane,  and  nerves  follows 
extending  from  within  outwards.  The  intestinal  canal  is  also  a  pos- 
sible way.  There  is  no  heredit}-,  and  what  we  looked  upon  as  hered- 
ity is  infection  favored  by  famih'  life. 

Hansen  entertains  the  same  view  as  Neisser,  though  he  refers  to 
mediate  transmission  through  clothing,  linen,  shoes,  and  the  furnish- 
ings of  the  habitations  of  lepers. 

Petersen  relates  a  case  in  which  the  primary  localization  was  in  the 
nose.  He  detected  the  presence  of  a  large  ulcer  on  the  left  side  of 
the  septum  the  secretions  from  which  were  rich  in  bacilli. 

In  the  official  examination  of  twelve  hundred  cases  reported  to  the 
Russian  Government,  the  disease  was  first  seen  in  the  extremities  in 
ninety-two  jjer  cent,  of  the  cases  of  nerve  leprosy.  In  one-half  the 
cases  of  the  tubercular  form  it  was  first  seen  on  the  face. 

Petersen  states  also  that  Professor  Munsch,  some  time  ago,  gave 
it  as  his  opinion  that  in  a  certain  number  of  cases  leprosy  commenced 
in  the  nose. 

Doutrelepont  is  inclined  to  accept  the  view  of  the  nasal  origin  of 
leprosy. 

Kaposi  denies  that  the  frequent  nasal  ulcerations  seen  in  lepers 
signify  that  the  nose  is  the  port  of  entry.  In  his  opinion  the  skin 
is  the  most  common  place  of  entrance  for  the  bacilli,  but  in  the  pres- 
ent state  of  our  knowledge  it  is  impossible  to  say  where  the  initial 
lesion  may  be. 

Besnier  says  the  principal  ways  of  projection  and  reception  of  the 
bacilli  are  the  mucous  surfaces — chiefly  the  nasal  cavities,  oculocon- 
junctival  and  buccal  ca^-ities,  pharyngeal  cavity,  cutaneous  surfaces, 
and  perhaps  the  digestive  tract. 

It  is  evident  from  the  very  comprehensiveness  of  these  views, 
.  including  almost  every  possible  mode  or  channel  of  entrance,  that 
our  knowledge  on  this  matter  is  only  conjectural.  Accurate  knowl- 
edge is  expressed  in  precise  rather  than  in  vague,  loose  terms. 

It  will  be  perceived,  however,  from  the  above-quoted  views  that 


CONDITIONS  INIXtJENcma  INFECTION.  459 

most  leprologists  incline  to  the  belief  that  infection  in  leprosy  takes 
place  through  the  mucous  membranes  of  the  upper  air  passages. 
This  theory  presupposes  the  aerial  transmission  of  the  bacilli,  as  it 
is  difficult  to  conceive  how  inoculation  of  these  surfaces  could  be 
effected  by  mediate  contact  with  objects  upon  which  the  bacilli  were 
accidentally  deposited. 

Several  years  ago,  before  the  investigations  of  Jeanselme  and 
Sticker,  upon  the  results  of  which  this  belief  is  based,  were  under- 
taken, the  writer  expressed  his  personal  views  as  follows : 

"  In  the  writer's  opinion,  most  observers  err  in  assuming  that  there 
is  one  exclusive  mode  of  infection  in  leprosy.  It  is  probable  that,  like 
the  bacilli  of  anthrax,  glanders,  and  tuberculosis,  the  mode  of  en- 
trance of  the  parasite  into  the  system  is  not  unique,  but  multiple. 
We  know  that  the  bacillus  of  tuberculosis,  which  presents  so  many 
analogies  with  leprosy,  may  enter  through  the  respiratory  tract,  the 
intestinal  mucous  membrane,  or  be  inoculated  through  the  skin.  I 
believe  that,  similarly,  the  bacillus  leprae  may  be  introduced  through 
more  than  one  channel  of  entrance.  Direct  inoculation  through  the 
skin,  in  any  of  the  manifold  ways  which  have  been  considered,  plays 
in  my  opinion,  a  very  unimportant  role  in  the  propagation  of  lep- 
rosy. In  the  vast  majority  of  cases,  I  believe  that  the  vehicles  of 
the  virus  through  which  contagion  is  effected  are  the  secretions  of 
the  nose  and  mouth,  and  that  the  port  of  entrance  is  the  mucous 
membrane  of  the  respiratory  and  intestinal  tract,  with  secondary  in- 
fection through  the  blood  or  lymi)hatic  system." 

My  observation  and  study  since  the  above  was  written  have  more 
than  ever  impressed  me  with  the  conviction  of  the  widespread  preva- 
lence of  infection  through  the  upper  air  passages.  If  it  be  estab- 
lished by  further  investigations  that  the  bacilli  leprae  most  frequently 
follow  the  aerial  route  in  penetrating  the  organism,  it  may  be  as- 
sumed that  they  find  in  this  locality  the  tissue  soil  most  suitable  for 
their  reception  and  growth. 

Conditions  Influencing  Infection. 

Individual  Predisposition. 

From  the  fact  that  in  countries  where  leprosy  is  endemic  and  the 
bacilli  are  abundant  many  are  exposed  but  few  are  infected,  it  is 
evident  that  predisposition  does  not  depend  upon  causes  which,  act- 
ing upon  all  alike,  would  reduce  the  entire  population  to  the  same 
degree  of  susceptibility,  but  upon  conditions  pertaining  to  the  indi- 
vidual.    The  whole  matter  of  individual  susceptibility  resolves  itself 


460  MORROW— LEPROSY. 

into  a  question  of  the  capabilities  of  the  body  to  restrict  and  limit 
the  growth  of  the  bacilli.  That  predisposition  must  exist  as  a  condi- 
tion of  leprous  infection  is  evident  from  the  observed  fact  that  certain 
individuals  are  absolutely  immune.  They  escape  the  disease  despite 
the  most  prolonged  and  intimate  contact  with  lepers  and  constant 
exposure  to  every  condition  favorable  to  the  communication  of  the 
germs.  Their  immunity  evidently  depends  upon  a  lack  of  receptiv- 
ity, or  a  greater  capacity  of  resistance  to  the  action  of  the  patho- 
genic agent. 

In  such  individuals,  even  though  infection  takes  place,  the  resist- 
ance of  the  tissues  to  the  inroads  of  the  bacilli  may  be  manifest  in 
the  further  evolution  of  the  malady,  which  is  exceedingly  slow  and 
protracted.  In  certain  cases  the  capacity  of  resistance  is  sufficient 
to  dominate  and  destroy  the  pathogenic  microbes.  Abortive  cases 
are  occasionally  seen  in  which  there  may  have  been  indubitable  signs 
of  leprosy  which  after  a  time  disappear  definitively,  and  the  persons 
remain  ever  afterwards  free  from  any  manifestation. 

Individual  predisi)osition,  whether  inherent  or  acquired,  must  be 
recognized  as  one  of  the  moat  powerful  factors  in  influencing  infec- 
tion. This  predisposition  may  be  constituted  by  a  native  weakness 
or  debility,  due  to  a  certain  type  of  conformation  or  peculiarity  of  tis- 
sue organization  which  renders  the  tissues  of  the  individual  more  vul- 
nerable and  less  capable  of  resisting  infection.  Those  physiological 
peculiarities  doubtless  determine  the  type  of  the  morbid  process 
according  as  the  cutaneous  or  nerve  structures  are  more  or  less  pre- 
disposed to  the  action  of  the  bacilli.  The  preferential  infection  of 
the  integument  in  the  tubercular  form  and  of  the  nerves  in  the  anaes- 
thetic form  can.  be  explained  only  on  the  ground  of  an  existing  pro- 
clivity in  the  tissues  of  the  individual  which  for  lack  of  a  better  term 
has  been  denominated  idiosyncrasy. 

But  quite  independent  of  this  inherent  organic  predisposition 
there  are  certain  accidental  conditions  of  a  general  or  local  nature 
which  create  a  pathological  predisposition  by  lowering  the  resistance. 
All  causes  or  conditions  which  impair  the  health  or  lower  the  vital- 
ity of  the  individual  predispose  to  contagion.  Excessive  work,  poor 
food,  privation,  misery,  bad  hygiene,  nervous  exhaustion,  etc.,  must 
be  placed  in  the  category  of  conditions  favoring  infection.  It  is  only 
upon  the  assumption  that  the  capacity  of  resistance  may  be  lowered 
by  various  causes  that  we  can  explain  those  cases  in  which  immunity, 
though  manifest  for  a  long  period,  may  finally  be  lost  and  the  indi- 
vidual fall  a  victim — just  as  in  tuberculosis  an  exemption  prolonged 
for  years  does  not  guarantee  an  absolute  permanent  immunity. 

In  addition  to  the  causes  acting  upon  the  general  economy,  certain 


CONDITIONS  INFLUENCING  INFECTION.  461 

local  conditions  may  influence  infection  by  creating  in  certain  tissues 
a  locus  mtvoris  resistentice  and  thus  permitting  the  entrance  of  the 
bacilli  through  this  weakened  part.  Even  after  the  bacilli  come  in 
contact  with  the  tissues  they  probably  lie  latent,  without  patho- 
genic action,  until  excited  into  activity  by  some  special  cause. 

The  more  our  bacteriological  knowledge  advances  the  more  we 
recognize  the  importance  of  pathological  modifications  in  the  organ- 
ism as  a  necessary  condition  of  the  growth  and  multiplication  of  bac- 
teria. There  are  manj'  morbid  germs  which  are  susceptible  of  be- 
coming pathogenic  but  manifest  their  virulence  only  under  special 
circumstances.  It  is  well  known  that  many  microbes  of  a  common 
order,  the  streptococcus,  the  pneumococcus,  the  colon  bacillus,  etc., 
though  capable  of  causing  serious  infections,  may  remain  upon  the 
cutaneous  or  mucous  surfaces  or  in  the  air  passages  absolutely  inert 
and  innocuous,  until  they  are  provoked  or  excited  into  activity  by 
some  pathological  change  which  creates  for  these  microbes  a  "  morbid 
opportunity." 

The  specific  microbes,  especially  those  of  tuberculosis  and  lep- 
rosy, would  seem  to  form  no  exception  to  this  rule.  It  is  probable 
that  they  lie  latent  upon  the  mucous  surfaces  of  the  air  passages  and 
await  their  opportunity  until  some  localizing  influence  creates  a  spe- 
cial aptitude  on  the  part  of  these  tissues  to  conceive  and  develop  their 
pathogenic  action. 

Prominent  among  the  local  conditions  which  influence  this  mode 
of  infection  I  would  place  the  inflammation  of  the  upper  air  passages, 
known  as  a  "cold"  or  a  "catarrh,"  which  so  often  precedes  the  de- 
velopment of  other  diseases. 

In  all  countries  where  leprosy  is  endemic  "a  cold"  followed  or 
not  by  fever  is  among  the  first  signs  of  ill  health.  In  South  Africa, 
according  to  Impey,  "if  you  ask  a  leper  how  he  contracted  the 
disease,  he  will  almost  invariably  reply  that  it  was  due  to  a  cold. 
I  am  of  opinion  that  cold  is  the  exciting  cause  of  leprosy.  The 
bacillus  lies  inactive  in  the  system  until  it  is  excited  into  action 
by  the  body  being  subjected  to  a  severe  cold."  Again,  in  speaking 
of  the  symptoms  of  the  tubercular  form:  "The  first  symptoms  of 
this  form  of  leprosy  usually  manifest  themselves  after  a  cold.  The 
patient  when  heated  has  a  cold  bath,  or  he  has  been  out  in  a  snow 
storm,  or  subjected  to  some  severe  cold  and  becomes  feverish.  He 
thinks  he  is  suffering  from  an  ordinary  catarrh  or  from  an  attack  of 
simple  fever." 

In  his  personal  observations  of  leprosy  in  Colombia,  Garces  says : 
"Most  people  attribute  the  origin  of  the  malady  to  cold  after  ex- 
posure, allowing  the  sudden  cooling  of  the  body  after  profuse  perspi- 


402  MORROW — LEPROSY, 

ration,  living  iu  damp  rooms,  going  from  a  lower  to  a  higher  alti- 
tude," etc. 

The  testimon}'  of  many  observers  in  leprous  countries  in  differ- 
ent quarters  of  the  globe  is  to  the  effect  that  "  a  cold"  is  most  fre- 
quently blamed  by  the  patient  as  the  starting-point  of  the  disease. 
The  catarrhal  condition  thus  engendered  may  not  only  favor  lej^rous 
infection  by  heightening  the  vulnerability  of  the  mucous  surfaces,  thus 
l)ermitting  a  ready  penetration  of  the  pathogenic  agent,  but  the 
changes  iu  the  tissues  caused  by  the  inflammatory  fluxion  maj-  create 
the  biochemical  conditions  favorable  to  the  germination  of  the  bacilli. 

Since  writing  the  above,  I  have  received  a  letter  from  Mr.  J.  Dut- 
ton,  who  has  charge  of  the  Home  for  Leper  Boys  in  the  Molokai 
settlement,  in  which  he  refers  to  the  modes  of  communication  of 
leprosy.  For  thirteen  years  he  has  been  in  intimate  daily  contact 
with  lepers,  and  his  opjiortunities  for  studying  the  disease  iu  all  its 
phases  give  his  observations  a  special  value.  He  says:  "I  cannot 
point  to  any  initial  lesion,  many  of  the  cases  are  advanced  when  I 
first  see  them."  ...  "I  shall  say  here,  however,  that  if  there  is  an 
initial  lesion  in  any  case,  something  in  the  skin  seems  to  have  that 
appearance.  I  have  always  thought,  however,  that  inhalation  has 
more  to  do  with  acquiring  the  disease  than  is  generally  supposed. 
The  mucous  surfaces  are  usually  much  affected  in  advanced  cases,  and 
also  in — I  should  say — a  decided  majority  of  cases  not  yet  old  or 
far  advanced.  I  have  wondered  if  leprosy  and  catarrh  do  not  find 
congenial  conditions  when  they  meet — a  sort  of  afiinity.  The  results 
in  man}^  cases — so  much  like  catarrh — emanate  from  leprosy,  but  the 
ulcerations  are  extensive  and  rapid.  I  have  also  wondered  if  the 
bacilli  are  really  the  first  invaders,  if  their  busy  duties  do  not  con- 
sist at  first  in  merely  occupying  tissues,  previously  made  ready,  in 
some  way  to  us  as  yet  mysterious  and  unexplainable." 

Unhygienic  Habits  and  Surroundhujs. — While  the  seed  and  the  soil 
are  the  essential  elements  in  the  production  of  leprosy,  it  is  obvious 
that  they  are  both  neutral  until  brought  into  conjunction.  For  the 
successful  cultivation  of  leprosy,  it  is  necessary  that  the  seed  be  im- 
planted in  the  soil.  The  intimate  and  s'ordid  contact  which  comes 
from  the  unhygienic  habits  and  surroundings  of  certain  races  or  peo- 
ples would  seem  to  constitute  the  most  effective  means  of  carrying 
out  this  condition.  This  view  is  supported  hy  the  observation  that 
in  all  countries  where  leprosy  has  rapidly  spread,  dirty  habits  and 
promiscuity  or  communism  in  the  matters  of  eating,  drinking,  and 
sleeping  prevail.  To  take,  for  example,  four  important  epidemic  cen- 
tres of  leprosy  within  the  past  century  : 


CONDITIONS  INFLUENCING  INFECTION.  463 

The  propagation  of  leprosy  in  Norway  lias  been  ascribed  as 
largely  due  to  tlie  unhygienic  habits  of  the  people.  According  to 
Leloir :  "  The  Norwegian  peasant  is  very  dirty.  The  greater  number 
of  the  peasants  have  never  taken  a  bath.  They  may  sometimes  wash 
(once  a  week)  the  face  and  hands,  and  the  feet  once  a  3'ear,  but  the 
other  parts  of  the  body  are  not  washed  from  the  day  of  their  birth  to 
that  of  their  death.  Their  clbthing  is  never  taken  off  even  for  the 
purposes  of  sleeping.  It  is  generally  made  of  wool.  Their  gar- 
ments are  never  washed.  Dirt  is  allowed  to  accumulate  upon  them, 
and  when  not  too  rotten,  they  are  often  transmitted  from  generation 
to  generation.  They  live  promiscuously  gathered  together  in  a  small 
house.  The  cabin  of  the  peasant  is  a  hut  made  of  firs  with  a  wooden 
roof  covered  with  earth,  upon  which  a  little  turf  is  placed.  The 
chimney  is  often  nothing  but  a  hole  made  in  the  roof,  and  the  rain 
falls  through  it  to  the  beaten  earth  which  forms  the  flooring.  Dung 
and  filth  are  accumulated  around  the  house  amidst  pools  of  dirty 
water.  Often  pigs,  poultry,  and  other  domestic  animals  live  with  the 
family.  Almost  always  several  persons  sleep  in  the  same  bed,  which 
is  nothing  but  a  kind  of  wooden  chest  upon  which  are  thrown  some 
sheep  skins  or  goat  skins  which  are  scarcely  ever  washed.  If  a 
stranger  comes  he  shares  the  bed.  Everybody  eats  at  the  same 
table,  from  the  same  dish,  often  with  a  common  spoon  and  drinks 
from  the  same  vessel." 

In  addition  the  Norwegian  peasants  are  weakened  by  poor  food, 
damp,  piercing  cold,  and  the  i^hysical  exertion  necessary  to  gain  a 
meagre  subsistence,  while  skin  disorders,  due  to  the  general  prev- 
alence of  scabies  among  them,  furnish  an  open  entrance  for  the 
lepra  bacilli  and  the  agents  of  putrefaction  as  well.  It  cannot  be 
considered  surprising  that  leprosy  rapidly  spreads  under  such  con- 
ditions, while  these  same  lepers,  transported  to  the  United  States  and 
adopting  the  more  civilized  customs  of  living,  with  greater  cleanliness, 
in  separate  newly  built  houses,  which  are  not  filthy  nests  of  conta- 
gion, have  not  spread  the  disease. 

Hansen  attributes  much  importance  to  the  habit  of  sleeping  in 
the  same  bed  with  lepers  in  connection  with  the  communication  of 
the  disease. 

Turning  now  to  another  important  centre,  we  find  that  while  the 
natives  of  the  Hawaiian  Islands  are  more  cleanly  in  their  persons, 
the  same  promiscuity  prevails  in  their  habits  of  li^^ing.  The  habits 
of  the  natives  of  the  Sandwich  Islands  have  been  thus  described  to 
me  by  Mr.  Meyer,  the  superintendent  of  the  leper  settlement  of  Molo- 
kai :  "  Their  modes  of  eating  are  so  extremely  careless  that  inocula- 
tion can  readily  take  place  through  the  mouth  by  means  of  the  saliva 


464  MORROW — LEPROSY. 

or  otherwise.  They  pass  their  pipes  from  mouth  to  mouth,  whether 
any  of  their  number  is  a  leper  or  not;  they  kiss  and  rub  their  noses 
together;  they  eat  out  of  the  same  calabash  with  their  fingers,  and 
drink  out  of  the  same  cup;  in  eating  fish  or  meat  it  is  not  cut  up, 
but  one  takes  the  meat  in  his  hand,  and,  after  taking  a  bite,  passes 
it  on.  They  drink  ova,  which  is  prejiared  by  others  chewing  the 
root,  and  whether  the  chewer  is  a  feper  or  not  is  not  considered. 
Foreigners  also  become  addicted  to  this  habit  of  ava  drinking,  and 
it  is  remarkable  that  most  of  the  foreigners  who  have  become  lepers 
were  ava  drinkers.  Most  of  them  have  been  mechanics,  and  the  only 
cause  to  which  they  ascribe  their  disease  is  having  worked  with 
lepers  and  handled  the  same  tools.  The  disease  ma}^  have  been 
communicated  in  some  instances  from  food  handled  by  lepers  in  an 
advanced  stage." 

In  Madagascar,  Dr.  Davison,  quoted  by  Hillis,  says :  "  Probably 
the  dirty  habits  so  prevalent  in  half-civilized  nations  must  tend  to 
aggravate  the  disease ;  eating  from  a  common  dish  with  the  fingers ; 
the  custom,  very  common  in  Madagascar,  of  interchanging  garments, 
and  of  all  lying  huddled  promiscuously  together  at  night  cannot  fail 
to  render  it  more  inveterate,  even  in  the  way  of  originating  it.  It 
certainly  deserves  notice  that,  while  the  laws  of  Madagascar  excluded 
leprous  persons  from  society,  the  disease  was  kept  within  bounds : 
but  after  they  were  permitted  to  fall  into  disuse,  it  has  si:)read  to  au 
almost  incredible  extent." 

In  New  Caledonia,  anoth'er  hotbed  of  leprosy,  the  conditions  of 
life  among  the  aborigines  are  thus  described  by  Dr.  Le  Grand: 
"Naked  or  almost  naked,  covered  with  mosquito  stings  and  scratches, 
they  lie  sleeping  in  their  smoky  huts  upon  dirt}^  mats.  The  rags 
which  serve  them  as  garments,  their  turbans,  their  handkerchiefs, 
their  pipes — all  is  in  common,  and  the  scanty  garde  robe  makes  often- 
times the  tour  of  the  tribe.  Place  among  them  a  leper,  the  secretions 
from  whose  ulcerations  are  diffused  over  the  garments,  the  mats,  and 
the  soil,  the  result  is  that  the  first  parts  attacked  are  the  parts  most 
intimately  brought  into  contact  with  objects  or  neighboring  bodies  in 
the  different  acts  of  common  life.  In  addition,  the  leper  in  New  Cale- 
donia has  the  detestable  habit  of  making  deep  ulcerations  in  his  spots 
and  tubercles  with  the  aid  of  pieces  of  glass,  treating  them  with  caustic 
applications,  etc.  In  addition  their  bodies  are  covered  with  a  thousand 
insignificant  hurts  from  insect  bites  and  scratches,  which  serve  as  ports 
of  sortie  in  diseased  persons,  and  ports  of  entry  in  healthy  persons." 

Dr.  Le  Grand  believes  that  leprous  contagion  is  effected  by  in- 
oculation, but  that  the  leper  is  contagious  only  at  an  advanced  stage, 
when  he  becomes  a  sort  of  "ambulant  ulcer." 


CONDITIONS  INFLUENCING  INFECTION,  465 

Climate. — From  the  extensive  geographical  distribution  of  leprosy 
it  is  evident  that  its  development  is  independent  of  conditions  of  cli- 
mate and  soil.  It  extends  from  the  tropics  to  the  Arctic  regions.  It  is 
found  in  damp  malarial  subtropical  regions  and  in  those  of  temperate 
non-malarial  zones.  It  is  disti'ibuted  through  the  length  and  breadth 
of  India.  On  this  continent,  it  prevails  in  both  marshy  and  mountain- 
ous regions,  in  the  lowlands  of  Louisiana  as  well  as  on  the  elevated 
tablelands  of  Mexico. 

While  the  widespread  and  diversified  distribution  of  leprosy  pre- 
cludes the  possibility  of  climate  per  se  being  invoked  as  a  causal  fac- 
tor, it  must  be  admitted  that  it  may  materially  influence  infection. 
As  a  rule  a  hot,  moist  climate  favors  the  development  of  leprosy  just 
as  a  cold,  damp  climate  does.  Leprous  patients  do  better  in  equable 
temperate  climates.  It  is  probable  that  a  propitious  climate  aids  in 
the  extinction  of  the  disease  by  its  favorable  influence  upon  the  gen- 
eral health  as  well  as  by  its  tendency  to  diminish  bacillary  virulence. 

Reference  has  already  been  made  to  the  observations  that  leprosy 
transplanted  to  this  climate  or  to  that  of  Central  Europe  does  not  take 
root  and  flourish,  and  each  centre  of  infection,  instead  of  spreading, 
dies  out  from  the  lack  of  conditions  favorable  to  its  development. 
So  far  as  we  can  apprehend  the  nature  of  these  inhibitory  conditions, 
a  major  importance  must  be  assigned  to  climate. 

In  the  dry,  cool  climate  of  our  Northwestern  States,  leprosy  does 
not  spread,  but  rather  tends  to  die  out  from  natural  causes ;  on  the 
other  hand,  the  warm  moist,  semiti'opical  climate  of  our  Southern 
seaboard  seems  favorable  to  its  development.  Just  as  in  the  case 
of  tuberculosis,  with  which  leprosy  presents  so  many  analogies,  cli- 
matic conditions  seem  to  lessen  or  reduce  its  infective  capacity  to  the 
point  of  extinction.  In  certain  parts  of  this  country,  as,  for  example, 
in  the  elevated  regions  of  the  Colorado  plateau,  tuberculosis  is  but 
feebly  contagious.  In  Colorado  Springs,  which  is  essentialh'  a  city 
of  homes  for  consumptives,  where  the  population  of  25,000  is  not 
transient,  as  in  many  health  resorts,  but  permanent,  carefully  com- 
piled statistics  show  that  during  twenty  years  there  had  been  only 
ten  deaths  from  non-imported  consumption.  Now  the  multitude  of 
consumptives  living  there  must  have  furnished  tubercle  bacilli  in 
plentiful  abundance  for  infection.  It  is  evident  that  in  certain  cli- 
mates it  is  more  difiicult  for  the  germs  of  both  tuberculosis  and  lep- 
rosy to  maintain  their  virulence  and  to  find  a  suitable  soil  in  the  body 
for  their  growth. 

Bace. — No  race  is  immune  to  leprosy.     We  must  recognize,  how- 
ever, that  racial  peculiarities  may  infliience  susceptibility  to  the  disease 
and  modify  its  mode  of  evolution. 
Vol.  XVIII.— 30 


466  MORROW — LEPROSY. 

Leprosy  is  decidedly  more  common  among  the  dark  than  the 
white  races.  In  the  far  East,  the  Mougolic  races  seem  to  exhibit  a 
si^ecial  susceptibility  to  the  disease ;  it  is  much  less  common  among 
the  Malays.  The  negroid  races  of  the  Philippines,  the  Malay  penin- 
sula, aud  the  tribal  representatives  of  this  race  in  Java  are  not  af- 
fected to  any  great  extent,  while  the  Chinese  (wherever  they  have 
emigrated)  form  the  bulk  of  the  lepers.  The  pure  Indian  races  of 
South  America  show  a  marked  immunity  as  compared  with  the 
African  aud  mixed  races.  The  same  observation  applies  to  the 
inhabitants  of  the  Antilles.  In  the  West  Indies  there  is  marked 
prop(m(leranc6  of  leprosy  in  the  negroes  over  all  other  races. 

Hillis  comments  iipon  the  remarkable  immunity  from  leprosy 
enjoyed  by  the  aboriginal  tribes  of  British  Guiana,  whereas  it  is  com- 
mon among  the  Bovianders  or  the  offspring  of  the  Indians  with  the 
Wack  or  colored  natives  of  the  colony.  This  immunity'  may  be  due 
to  their  open-air  life,  their  habits  of  cleanliness,  and  their  isolation. 
He  instances  as  a  remarkable  fact  that  the  Warroo  tribe,  which  was 
the  only  native  tribe  that  constantly  associated  with  the  negro  lepers, 
alone  became  contaminated,  and  that  leprosy  prevails  among  their 
descendants  to  the  present  day,  while  no  other  Indian  tribe  has  be- 
come affected. 

The  extraordinarily  rapid  increase  and  terrible  mortality'  of  leprosy 
among  the  natives  of  the  Sandwich  Islands  must  be  ascribed  partly 
to  the  habits,  but  largely  to  the  racial  qualities,  of  this  people.  They 
have  a  feeble  vital  tenacity ;  their  capacity  of  resistance  is  small,  and 
they  succumb  readilj^  to  diseases  from  which  the  average  Anglo- 
Saxon  easily  recovers. 

Age. — While  leprosy  attacks  persons  of  all  ages,  from  infancy  up 
to  fourscore,  or  even  fourscore  and  ten,  the  greatest  incidence  of  the 
disease  seems  to  fall  in  the  third  decade,  from  twenty  to  thirty 
years.  It  would  ai)pear  that  tubercular  leprosy  attacks  the  patient 
at  an  earlier  age  than  the  anaesthetic  form,  or  at  least  the  first  mani- 
festations are  several  years  earlier;  Hillis  says  ten  years. 

Sex. — There  is  an  undoubted  predisposition  to  leprosy  conferred 
by  sex.  In  all  leprous  countries  the  number  of  males  who  suffer 
from  leprosy  is  always  in  excess  of  that  of  females.  This  proportion 
varies  somewhat  in  different  countries.  In  Norwaj^  among  7,302 
cases  there  were  4,164  men,  3,183  women.  In  Iceland,  about  the 
same  proportion — 4  men  to  3  women.  In  Bosnia  and  Herzegovina 
Neuman's  statistics  gives  116  men  to  16  women.  In  Cape  Colony 
Impey's  statistics  show  1,296  males  to  475  females.  In  British 
Guiana  the  proportion  is  about  3  males  to  1  female.  In  Hawaii  the 
number  of  male  lepers  is  about  double  that  of  the  females. 


SYMPTOMS  AND  COUBSE.  467 

This  disproportion  in  the  incidence  of  the  disease  in  the  two  sexes 
may  be  due  partly  to  occupation,  the  males  being  more  exposed  to 
vicissitudes  of  weatheij  and  from  their  manual  labor  more  liable  to  in- 
juries resulting  in  broken  surfaces  and  wounds.  In  Eastern  countries 
the  rooted  aversion  of  the  women  to  see  foreign  doctors  and  the 
strict  seclusion  in  which  women  are  habitually  kept  by  the  rule 
of  Mohammedan  tradition  doubtless  make  the  discrepancy  appear 
greater  than  it  really  is.  In  Hong-Kong,  for  example,  statistics 
show  that  of  125  lepers  there  were  only  1.3  females,  or  10.4  per  cent. 


SYMPTOMS  AND   COURSE. 

"While  tubercular  leprosy  is  not  sufficiently  regular  in  its  evolution 
to  admit  of  its  division  into  distinct  stages  or  periods,  we  may,  for  the 
convenience  of  clinical  description,  speak  of  (1)  a  period  of  invasion, 
(2)  a  period  of  erythematous  eruption,  (3)  a  period  of  tubercular 
eruijtion,  and  (4)  a  period  of  ulceration,  succeeded  by  a  final  period 
in  which  the  clinical  symptoms  constantly  increase  in  intensity  and 
severity  owing  to  the  continued  degeneration  of  the  tissues  and  the 
diminished  vitality  of  the  organism  damaged  by  the  multiplication  of 
the  bacilli  and  their  toxins,  as  well  as  by  the  absorption  of  the  prod- 
ucts of  suppuration. 

It  must  be  borne  in  mind,  however,  that  in  the  ordinary  evolution 
of  tubercular  leprosy  the  cutaneous  manifestations  do  not  develop  in 
an  order  sufficiently  regular  or  uniform  to  enable  us  to  draw  distinct 
lines  of  demarcation  between  these  stages.  There  is  no  sharp  chron- 
ological limitation  of  the  erythematous  eruption.  This  form  of  qx- 
anthem  may  and  commonly  does  recur  coincidently  with  the  eruption 
of  tubercles  and  may  continue  its  outbreaks  during  the  entire  course 
of  the  disease.  During  the  active  neoplastic  period  many  of  the 
tubercles  may  become  ulcerated  or  disappear  by  a  process  of  resorp- 
tion long  before  the  ulcerative  phase  of  the  disease  becomes  definitely 
established. 

Likewise  in  describing  the  course  of  anaesthetic  leprosy  we  recog- 
nize (1)  a  period  of  invasion,  (2)  an  eruptive  stage,  (3)  an  atrophic 
stage  attended  with  tendinous  retractions,  deformities,  and  anaesthe- 
sia, and  (4)  an  ulcerative  stage  with  consecutive  mutilations. 

Strictly  speaking,  the  macular  lesions  of  this  form  are  practically 
permanent  and  persistent  during  the  entire  course  of  the  disease. 
Anaesthesia  is  also  a  more  or  less  fixed  feature  and  may  coexist  with 
hyperaesthesia.  Ulcerations  and  deformities,  while  common  and 
characteristic,  are  by  no  means  invariable  features. 


468  MORROW— LEPROSY. 

It  will  thus  be  seen  that  any  schematic  arrangement  is  one  of  con- 
venience rather  than  of  scientific  accuracy.  It  is  intended  only  to 
outline  the  general  course  of  the  disease  and  indicate  the  more 
prominent  phases  which  it  successively  exhibits  in  its  ordinary  evo- 
lution. 

The  manifestations  of  leprosy  present  the  widest  variations  in 
character,  morbid  activity,  and  the  intervals  which  separate  their 
outbreaks.  The  explanation  of  the  apparently  capricious  character 
of  the  leprous  process  which  is  especially  marked  in  the  earlier  stages 
must  be  sought  for  in  the  tendency  of  the  bacilli  to  multiply  at  irreg- 
ular intervals,  periods  of  activity  alternating  with  periods  of  quies- 
cence and  repose. 

It  will  be  convenient  to  study  the  invasive  period  of  tubercular 
and  anaesthetic  leprosy  together,  since  the  i)henomena  of  this  period 
present  nothing  absolutelj^  characteristic  of  either  form. 

Period  or  Invasion  or  Incubation. 

The  term  "  invasion"  is  employed  in  this  connection  with  a  clear 
comprehension  of  the  fact  that  there  is  not  in  leprosy,  as  in  certain 
other  infectious  diseases,  a  rapid  and  general  intoxication  of  the  sys- 
tem, but  that  during  the  entire  life  term  of  the  malady  there  may  be 
repeated  and  progressive  invasions  by  the  bacilli  and  their  toxins  of 
structures  previously  exempt.  The  phenomena  of  this  period  present 
nothing  absolutely  characteristic;  they  are  essentially  transitory  and 
uncertain,  and  in  many  cases  they  may  be  so  slight  as  to  pass  unper- 
ceived  by  the  patient. 

Leloir  has  suggested  that  the  invasion  period  of  leprosy  i)resents 
certain  analogies  with  the  period  of  the  secondary  incubation  of  syphi- 
lis or  with  the  prodromal  period  of  certain  forms  of  tuberculosis. 

The  claim  of  recent  investigators,  that  leprosy  has  an  initial  lesion, 
would,  if  demonstrated  to  be  constantly  present,  indicate  a  closer 
analogy  between  the  primarj^  phases  of  leprosy  and  syphilis  than  has 
hitherto  been  suspected.     This  leads  to  the  inquiry : 

Has  Leprosy  an  Initial  Lesion  ?  The  fact  that  the  first  cutaneous 
manifestations  of  leprosy  commonly  occur  upon  exposed  parts — the 
face,  hands,  or  feet — in  the  form  of  erythematous  spots  has  led  to  the 
opinion,  still  held  by  many  observers,  that  these  spots  represent  the 
initial  lesion,  from  which,  as  infective  centres,  the  germs  are  distrib- 
uted. 

Arning  has  reported  an  instance  of  what  he  regards  as  a  primary 
localization  of  the  virus  in  the  skin.  The  patient  came  from  a  non- 
leprous  part  of  the  United  States  to  Honolulu.     Three  months  after 


SYMPTOMS  AND  COUESE.  469 

her  arrival  slie  noticed  a  small,  red,  slightly  raised  spot  ou  the  left 
forearm,  which  slowly  enlarged  and  in  a  year  became  anaesthetic. 
Two  years  later  a  group  of  papules  developed  around  it.  Lepra 
bacilli  were  found  abundantly  in  the  tissues. 

Kaposi  reports  a  case  of  what  he  regarded  as  the  initial  lesion 
upon  the  finger  of  a  patient  in  the  form  of  a  bulla,  which  the  bearer 
thought  was  caused  by  the  sting  of  an  insect.  Later  the  face  became 
infiltrated  with  anaesthetic  lepromes.  Hillis  says  that  "  if  leprosy 
may  be  introduced  through  the  integument,  the  initial  lesion  must  be 
an  ill-defined  erythematous  spot,  soon  followed  by  other  macules  in 
the  vicinity  or  any  other  part  of  the  body."  Blanc  asserts  that  this 
sort  of  history  was  received  from  a  number  of  his  patients,  and  that 
in  one  case  such  a  lesion  came  under  his  observation. 

In  the  vast  majority  of  cases,  however,  in  which  the  date  of  infec- 
tion can  be  fixed  with  approximative  certainty  within  narrow  limits, 
the  erythematous  spots  do  not  appear  for  months  or  j'ears  later  and 
during  this  time  the  presence  of  certain  prodromal  sj'mptoms  indi- 
cates clearly  that  systemic  derangement  is  already  in  progress.  Be- 
sides, the  presence  of  these  spots  is  not  an  absolutelj^  constant  feature 
which  invariably  precedes  the  development  of  tubercles  or  degenera- 
tive changes  in  the  nerves.  The  leprous  spots  must  be  regarded 
not  as  a  primary  lesion  from  which  autoinfection  takes  place,  but 
rather  as  the  evidence  of  an  already  accomplished  infection  of  the 
system. 

The  writer's  views  upon  this  point  were  expressed  several  years 
ago  as  follows  (Morrow's  "System  of  Genito-Urinary  Diseases, 
Syphilology,  and  Dermatology") :  "There  is,  so  far  as  we  can  deter- 
mine, no  initial  lesion  of  the  integument.  It  is  probable  that  in  the 
mucous  surfaces  of  the  upper  air  passages,  the  pituitary  or  pharyn- 
geal membrane,  or  other  ports  of  entrance  of  the  virus  there  may  be 
an  initial  patch  which  serves  as  an  incubating  medium  for  the  bacilli 
before  they  become  more  generallj-  diffused  through  the  system. 
This  view  is  quite  in  accordance  with  our  knowledge  of  the  modes  of 
infection  in  glanders,  tuberculosis,  and  other  bacillary  diseases.  But 
there  is  no  evidence  whatever  to  show  that  leprosy  has  a  primary 
lesion  of  the  external  parts  which  corresponds  in  any  way  to  the  in- 
itial lesion  of  syphilis." 

These  conclusions,  at  which  I  arrived  several  years  ago  and  which 
were  based  upon  my  clinical  studies  of  the  disease,  would  seem  to  be 
confirmed  by  bacteriological  proof.  The  recent  bacteriological  inves- 
tigations of  Sticker  and  of  Jeanselme  and  Laurens,  the  results  of  which 
were  submitted  to  the  Berlin  Leprosy  Congress  (1897),  and  to  which 
reference  is  elsewhere  made,  would  seem  to  substantiate  my  state- 


470  MORROW — LEPROSY. 

ment  that  the  lepra  bacilli,  in  many  cases  at  least,  are  first  depos- 
ited upon  the  nasal  mucous  membrane,  which  constitutes  a  favorable 
culture  ground  for  their  multiplication  and  subse^iueut  dissemination 
through  the  system. 

Of  the  one  hundred  and  fifty -three  cases  studied  bacteriologically 
by  Sticker,  evidences  of  lej^rous  changes  in  the  nasal  mucous  mem- 
brane were  found  in  all  but  thirteen.  He  maintains  that  these 
changes  caused  by  the  bacilli  constitute  the  initial  lesion  of  leprosy, 
which  he  thus  describes :  "  It  is  an  ulcer,  rarely  a  tubercle,  situated 
upon  the  nasal  mucous  membrane,  usually  the  cartilaginous  portion. 
It  is  usually  simply  erosive;  it  may  be  more  or  less  penetrating  and 
ultimately  leads  to  necrosis  of  the  osseous  framework  of  the  nose." 
The  best  evidence  that  this  is  the  primary  focus  he  finds  in  the 
peculiar  distribution  of  tlie  early  lepromata  of  the  face,  which  indi- 
cates dissemination  of  the  parasite  by  the  lymph  channels.  These 
nasal  changes,  he  asserts,  often  precede  by  several  years  the  fir.st 
cutaneous  nodules  or  the  first  nervous  symptoms  and  may  persist  dur- 
ing the  entire  course  of  the  disease  as  an  active  centre  of  autoinfection 
as  well  as  of  contagion. 

Jeanselme  and  Laurens  found  lei:)rous  lesions  of  the  nasal  fossae, 
the  mouth,  throat,  and  larj'nx  in  sixty  per  cent,  of  the  twenty-six 
cases  examined  by  them.  They  conclude  that  the  bacilli  first  pene- 
trate into  the  organism  through  an  insignificant  erosion  of  the  pitui- 
tary membrane,  and  that  the  alterations  of  the  nasal  mucosa  constitute 
the  first  exterior  manifestation  of  leprosy.  Thus  is  explained  how 
the  leprous  chancre  hidden  in  the  anfractuosities  of  the  nasal  fossae 
always  passes  unperceived. 

These  observers  make  the  important  reservation  that  this  hy- 
pothesis, however  plausible  in  certain  cases,  should  not  be  generalized 
in  all,  since  in  certain  subjects  leprous  coryza  does  not  appear  until 
the  disease  is  fully  developed.  This  view  coincides  with  that  ex- 
pressed hj  myself  (/.  c.)  that  the  nasal  mucous  membrane  is  not  the 
sole  port  of  entrance,  as  the  mode  of  infection  in  leprosy  is  not  unique 
but  multiple. 

Incubation. — Even  admitting  the  existence  of  a  leprous  initial 
lesion  in  the  nasal  fossae  as  more  or  less  constant,  we  have  no  data, 
since  the  moment  of  contagious  contact  is  always  indeterminable, 
which  would  enable  us  to  establish  the  period  of  its  incubation  or 
what,  from  its  assumed  analogies  with  syy)hilis,  might  be  termed  the 
period  of  primary  incubation.  For  the  recognition  of  leprosy  the  so- 
called  leprous  chancre  is  practically  non-existent,  since  we  are  unable 
to  identify  the  disease  before  the  advent  of  certain  symptoms  which 
point  to  a  systemic  infection. 


SYMPTOMS   AND   COUKSE.  471 

The  incubation  of  leprosy  is  understood  to  embrace  that  period 
which  elapses  between  the  introduction  of  the  bacilli  into  the  system 
and  the  appearance  of  visible  signs  of  the  disease  upon  the  cutaneous 
surface  or  the  evidences  of  characteristic  changes  in  the  peripheral 
nerves.  This  period  varies  within  wide  limits  and  is  often  very  pro- 
tracted. 

It  is  probable  that,  for  a  time  at  least,  the  bacilli  remain  dormant 
and  inactive.  No  sign,  local  or  constitutional,  indicates  that  infecr 
tion  has  taken  place.  We  do  not  know  what  process  of  preparatioE 
may  be  taking  place  during  this  period  of  apparent  quiescence. 
Whether  there  is  a  real  sleep  or  hibernation  of  the  germ,  as  is  main- 
tained by  Besnier — a  latent  phase  analogous  to  that  of  a  seed  whici 
conserves  for  a  time  more  or  less  prolonged  its  torpid  life  until  the 
moment  when  its  germinative  conditions  are  realized — can  only  be  con- 
jectured. Certainly  the  subsequent  reactions  which  show  that  the 
seed  has  germinated  and  become  endowed  with  virulence  and  infec- 
tive capacity  may  not  be  in  evidence  until  months  or  years  later,  li 
would  appear  probable  that  if  the  tissue  upon  which  they  are  first 
deposited  is  inapt  for  their  propagation,  they  are  carried  to  and  fro 
in  the  lymphatic  circulation  until  they  find  somewhere  a  favorable 
soil  for  their  germination  and  growth.  From  this  source  of  genera- 
tion the  bacilli  are  transplanted  to  other  culture  grounds,  which  ia. 
turn  constitute  fresh  foci  of  infection  until  a  more  or  less  general  in- 
fection takes  place. 

During  this  process  of  invasion  of  the  system  by  the  multiplica- 
tion of  bacilli  and  the  creation  of  new  centres  of  autoinfection  theia 
are  usually  certain  constitutional  reactions,  to  be  described  in  connec- 
tion with  the  prodromes,  which  mark  a  phase  in  the  evolution  of  the 
disease  and  furnish  clinical  evidences  that  the  implanted  germs  are 
active. 

The  duration  of  the  'period  of  incubation  varies  within  wide  limits 
and  may  be  quite  protracted.  It  has  been  variously  estimated  at  from 
a  few  weeks  or  months  to  several  years — three,  five,  twenty  years  or 
longer.  In  countries  where  leprosy  is  endemic  and  where  there  i& 
more  or  less  constant  exposure  to  the  chances  of  contagion  it  is  im- 
possible to  determine  this  point. 

Observations  have  been  made  in  cases  in  which  a  leper  has  removed 
from  an  infected  to  a  healthy  district  and  has  communicated  the  dis- 
ease to  persons  previously  exempt  from  any  possible  exposure.  Ln 
these  cases  the  period  which  elapses  between  the  coming  of  the  leper 
and  the  date  of  the  first  leprous  manifestations  in  others  has  been 
taken  as  the  basis  of  calculation.  Obviously,  however,  conclusions 
founded  upon  such  a  basis  are  loose  and  unsatisfactory,  since  weeks 


472  MORROW— LEPROSY. 

or  months  may  elapse  before  there  is  a  concurrence  of  conditions 
favorable  to  infection. 

An  estimate  based  ui)on  the  observation  of  persons  without  lep- 
rous antecedents  who  have  been  exposed  for  the  first  time  in  travel- 
ling or  passing  a  limited  time  in  a  leprous  country,  and  who  have 
developed  the  disease  after  their  return,  may  be  accepted  as  approxi- 
mately correct.  But  even  here,  unless  they  can  fix  definitel}^  upon 
the  time  and  circumstances  of  a  known  exposure,  or  tho  duration  of 
their  stay  has  been  brief,  it  is  evident  that  such  calculation  is  open  to 
error.  Thus  I  have  been  consulted  by  a  patient  who  lived  eight  years 
in  South  America  without  any  known  exposure  and  who  showed  no 
signs  of  the  disease  until  shortl}^  after  his  return  to  this  country.  Now 
in  this  case  it  is  not  possible  to  determine  at  what  period  of  his  stay 
he  received  the  infection.  It  may  have  been  soon  after  going  there  or 
immediatel}^  preceding  his  return.  In  another  case  under  my  obser- 
vation a  patient  who  had  spent  two  weeks  in  the  Sandwich  Islands 
presented  undoubted  symptoms  of  leprosy  within  ten  months  after 
his  return.  Arning's  case,  in  which  leprosy  developed  within  three 
months  after  the  arrival  of  the  j)atient  in  Hawaii  from  a  non-leprous 
part  of  the  United  States,  has  alreadj'  been  referred  to. 

Bidenkap  reports  a  ease  in  which  the  incubation  was  of  only  a  few 
weeks'  duration.  Impey  (South  Africa)  says :  "  While  bacilli  may 
be  in  the  system  for  years  before  producing  signs,  I  know  of  a  case  in 
which  symptoms  of  leprosy  were  produced  within  three  months  after 
their  introduction.  In  the  majority  of  cases  it  does  not  exceed  two 
years." 

As  examples  of  prolonged  incubation,  Daniellsen  and  Boeck, 
Leloir,  and  others  report  cases  in  which  the  duration  of  this  period 
varied  from  ten  to  twenty  or  even  thirty  years.  In  almost  all  these 
cases  the  patient  had  removed  from  a  leprous  district  to  a  country 
where  the  disease  was  not  endemic. 

According  to  Besnier,  one  cannot  accept  the  idea  that  persons  who 
have  emigrated  from  leprous  countries  and  who  have  developed  the 
first  signs  of  the  disease  dozens  of  years  later  in  non-leprous  countries 
present  a  real  incubation  of  such  length.  "This  delay,"  he  says, 
"  can  be  due  only  to  the  conservation  of  the  bacillus  in  an  inert  state 
in  some  neutral  part  of  the  organism.  This  period  of  silence  corre- 
sponds not  to  a  gradual  germination  of  the  pathogenic  agent,  but  to 
a  real  sleep,  a  hibernation  of  the  germ."  "True  incubation  compre- 
hends the  time  which  elapses  between  the  moment  when  the  lepra 
bacillus  reaches  an  opportune  place,  finds  the  exclusively  human 
biochemical  elements  necessary  to  its  multiplication,  and  setting  it  in 
action,  and  the  moment  when  the  first  leprous  manifestations  occur. 


SYMPTOMS  AND  COUESE.  473 

This  duration  varies  according  to  the  anatomical  place  of  its  _ocali- 
zatiou  and  the  vital  conditions  of  the  invaded  tissues,  but  it  does  not 
necessarily  exceed  an  average  of  several  months." 

I  am  convinced  from  my  observation  of  a  number  of  patients  who 
have  consulted  me  that  the  period  usually  accorded  by  most  text-book 
writers  to  the  incubation  of  leprosy  is  much  longer  than  it  actually  is. 
By  careful  questioning  of  many  lepers  who  have  contracted  the  dis- 
ease abroad  I  have  found  that  their  initial  symptoms,  many  of  which 
they  had  paid  no  attention  to  or  had  almost  forgotten,  antedated  by 
several  months  or  even  years  the  appearance  of  symptoms  recognized 
as  leprous. 

It  is  probable  that  many  cases  recorded  in  literature  as  examples 
of  prolonged  incubation  may  have  had  for  years  symptoms  undoubt- 
edly leprous,  but  of  so  mild  and  equivocal  a  character  that  their  true 
nature  was  misinterpreted  and  referred  to  rheumatism,  malaria,  or 
some  other  malady.  Besides,  it  must  be  remembered  that  the  initial 
symptoms  of  leprosy  are  so  variable,  uncharacteristic,  and  absolutely 
indefinite  that  they  never  would  be  ascribed  to  leprosy  in  any  country 
where  the  disease  was  not  endemic  or  there  were  not  decided  reasons 
for  suspecting  its  presence. 

Among  the  conditions  which  contribute  to  advance  or  materially 
retard  the  date  of  development  of  leprous  symptoms  are  the  state  of 
the  patient's  health,  climate,  food,  habits  of  living,  etc.,  and,  as  in  the 
case  of  other  infectious  diseases,  the  slower  the  action  of  the  patho- 
genic agent  the  more  likely  is  it  to  be  affected  by  extraneous  influ- 
ences. 

The  duration  of  the  period  of  incubation  is  not  determined  solely 
by  the  specific  germ,  but  depends  ui)on  conditions  of  individual 
receptivity.  The  germination  of  the  seed  is  especially  subordinate 
to  conditions  of  the  soil.  The  resistance  of  the  patient's  tissues  to 
the  bacillarj'  invasion  is  one  of  the  principal  factors  in  lengthening 
this  period.  Poverty,  dirt,  poor  alimentation,  and  unhealthy  sur- 
roundings have  been  the  appurtenances  of  leprosy  in  all  countries 
and  in  all  ages.  Where  persons  live  in  low,  damp  habitations  with 
malarial  surroundings  and  frequently  exposed  to  cold  and  wet  the 
bacillus  is  excited  into  activity  and  the  incubation  is  shorter.  All 
observation  goes  to  show  that  the  removal  of  a  person  from  a  leprous 
to  a  non-leprous  country  tends  to  retard  the  development  of  the  disease. 


474  MORROW — LEPROSY. 


Prodromes. 

Ill  the  majority  of  cases  tliere  are  certain  prodromal  symptoms 
more  or  less  pronounced,  but  exceedingly  variable  in  their  character 
and  order  of  development,  which  precede  the  outbreak  of  the  eruptive 
phenomena.  While  they  are  not  sufficiently  characteristic  to  indicate 
with  certainty  the  nature  of  the  disease,  they  give  evidence  that  some 
sort  of  systemic  deraugeiiieut  is  already  in  progress  long  before  any 
outward  signs  furnish  the  necessary  confirmation  of  the  diagnosis. 
In  the  present  state  of  our  knowledge  it  is  impossible  to  determine 
the  pathological  basis  of  these  prodromal  phenomena.  We  do  not 
know  whether  they  are  due  to  the  topical  effects  of  the  bacteria  or  to 
a  more  or  less  general  intoxication  by  the  chemical  products  or  toxins 
of  the  microorganisms. 

It  is  probable  that  the  mode  of  onset  of  leprosy  is  analogous  to 
that  of  tuberculosis,  in  which  local  or  constitutional  symptoms,  such 
as  haemoptysis,  laryngitis,  or  bronchitis,  may  be  evident  long  before 
there  is  a  general  invasion  of  the  pulmonary  tissues  by  the  bacilli. 

The  constitutional  reaction  does  not  necessarily  imply  that  there 
is  a  general  infection,  but  only  that  there  is  a  disturbing  cause  at 
work  in  some  part  of  the  organism.  In  the  case  of  anaesthetic  leprosy, 
it  would  simplify  our  conception  of  the  morbid  process  and  at  the 
same  time  be  reconcilable  with  the  clinical  evidence  to  assume  that 
the  phenomena  of  this  stage  are  the  expression  of  a  peripheral  neuritis, 
due  to  the  impression  of  the  bacteria  and  their  toxins  upon  these 
structures,  and  entirely  independent  of  any  central  nervous  trouble. 

Febrile  Symptoms. — Fever  is  a  more  or  less  constant  feature  of  the 
tubercular  form  of  leprosy  and  may  be  considered  as  the  most  impor- 
tant initial  symjitom.  The  types  of  leprous  fever  vary.  In  malarial 
regions  it  is  commonly  of  the  intermittent  type.  Many  lepers  date 
the  beginning  of  their  disease  to  an  exposure  to  cold,  followed  by  an 
attack  of  what  they  considered  at  the  time  malarial  fever.  It  has 
been  observed  that  this  mode  of  origin  is  more  apt  to  occur  among 
jiersons  who  live  in  damp,  swampy  localities,  and  it  is  possible  that 
their  malarial  environment  exercises  a  predominant  role  in  determin- 
ing the  febrile  access.  The  febrile  concomitants  of  the  outbreaks  of 
leprosy  at  a  later  stage  are  probably  due  to  the  invasion  of  new  parts 
of  the  body  by  the  bacilli  and  the  toxic  effect  produced  by  their 
emanations. 

In  perhaps  the  majority  of  cases  the  fever  is  of  the  remittent  type. 
The  febrile  access  is  more  apt  to  come  on  during  the  afternoon  or 
evening,  attain  its  maximum,  and  be  followed  by  a  remission  in  the 


SYMPTOMS  AND  COUKSE.  475 

morning  and  forenoon.  Wliile  tlie  fall  of  the  fever  may  be  attended 
with  moderate  sweating,  it  contrasts  in  this  respect  with  the  drench- 
ing perspiration  so  common  and  distressing  a  feature  of  tuberculosis. 
Weakness  and  Prostration. — Coincident  with  the  febrile  paroxysms 
there  oftentimes  exists  a  very  marked  degree  of  prostration,  which 
may  continue  after  the  febrile  symptoms  have  passed.  Patients  com- 
plain of  weakness,  of  an  indisposition  for  exertion,  and  of  an  inclina- 
tion to  sleep. 

Digestive  Troubles. — Loss  of  appetite,  nausea,  difficult  digestion, 
and  other  morbid  stomachal  conditions  are  among  the  earlier  mani- 
festations. 

While  anaemia  is  common  as  a  result  of  the  digestive  disorders,  the 
progressive  emaciation  which  is  so  pronounced  a  feature  of  tubercu- 
losis is  not  common  in  leprosy. 

Upistaxis. — Among  the  local  symptoms  rhinitis,  often  attended 
with  a  sense  of  tickling,  sneezing,  coryza,  and  not  infrequently  with 
epistaxis,  more  fitly  belongs  to  the  prodromal  period  than  to  the  later 
one  to  which  it  is  usually  assigned. 

Leloir  regarded  the  epistaxis  of  leprosy  as  similar  in  nature  to 
the  prodromal  epistaxis  of  typhoid  fever,  incipient  tuberculosis,  and 
other  infectious  diseases.  Later  investigations  would  indicate  that  it 
is  a  specific  rather  than  a  symptomatic  manifestation,  the  pathologi- 
cal basis  of  which  is  the  existence  of  primary  leprous  foci  in  the 
nasal  mucous  membrane.  Their  presence  would  explain  the  precocity 
as  well  as  the  comparative  constancy  of  the  irritative  symptoms. 
This  mild  epistaxis,  which  proceeds  from  congestion  of  the  nasal  mu- 
cosa, is  not  to  be  confounded  with  the  epistaxis  which  results  from 
ulceration  of  the  pituitary  membrane  and  other  destructive  changes 
manifest  at  a  later  period.  L-ritative  symptoms  of  the  nose  are  much 
more  common  in  the  tubercular  form. 

jTJie  prodromes  of  the  ancesthetic  foron  are  much  more  variable  in 
kind  and  degree  and  are  distinguished  by  their  more  marked  neurotic 
character,  pointing  to  the  active  participation  of  the  nervous  system 
in  their  production. 

From  the  relatively  small  number  of  bacilli  in  this  form  general 
systemic  disturbance  is  not  so  pronounced  as  in  the  tubercular  form. 
Disorders  of  sensation  constitute  the  most  constant  and  characteristic 
feature  of  the  prodromal  period  of  anaesthetic  leprosy. 

Formication  and  pruritus,  tingling  and  pricking,  burning  pains  of 
the  surface,  which  vary  in  degree  of  intensity,  oftentimes  of  a  severe 
character,  are  common  in  the  invasive  period.  Some  patients  can- 
not keep  still  from  the  imperious  desire  to  rub  and  scratch  the 
limbs.     At  night  the  sensation  is  not  entirely  dulled  by  sleep,  evi- 


476  MORROW — LEPROSY. 

dences  of  which  may  be  manifest  iu  the  morning  in  the  shape  of 
scratch  marks  unconsciously  inflicted. 

One  of  m\'  patients  described  the  sensation  as  that  which  attends 
the  contact  of  air  or  water  with  a  freshly  abraded  surface.  On  more 
than  one  occasion,  as  he  informed  me,  he  removed  his  shoe,  feeling 
assured  that  he  would  find  an  abrasion  of  the  surface.  These  sensa- 
tions are  not  invariably  present,  but  are  more  or  less  intermittent  in 
character.  They  are  exceedingly  capricious  in  their  seat,  first  in  one 
locality,  then  in  another. 

These  hypersesthetic  symptoms,  which  are  doubtless  due  to  irrita- 
tion of  the  peripheral  nerves,  are  not  confined  to  the  skin.  Tender- 
ness and  pain  of  a  lancinating,  boring  character  may  be  felt  in  the 
deeper  structures,  usually  in  the  extremities,  in  the  toes  or  heel,  about 
the  ankle,  often  associated  with  a  sense  of  stiffness  and  weight  of  the 
members. 

Cephalalgia  sometimes  accompanied  with  vertigo  has  been  noted 
among  the  precursory  signs  of  ansesthetic  leprosy.  The  cephalalgia 
varies  in  intensity  and  severity,  and  is  usuallj^  more  pronounced  in 
the  evening.  The  i)ain  is  more  apt  to  be  localized  at  the  back  and 
base  of  the  brain,  and  may  be  quite  persistent. 

Various  ahjias  and  rht'iiniatoid 2^ciiiis,  especially  in  the  lower  limbs, 
may  be  present  in  the  prodromal  period. 

Disorders  of  the  suchrvparous  and  sebaceous  glauds,  although  much 
more  pronounced  later  in  the  evolution  of  the  disease,  may  neverthe- 
less be  manifest  in  the  prodromal  stage.  The  first  evidence  of  irregu- 
larity is  usually  observed  in  the  abnormal  excitability  of  the  sweat 
glands,  which  i)our  out  their  secretion  spontaneously  or  under  the 
influence  of  light  exercise,  which  normally  would  not  provoke  this 
secretion.  This  hy  peridrosis  does  not  depend  upon  anaemia  or  general 
weakness  as  in  tuberculosis,  but  is  due  to  vasomotor  disturbance  from 
peripheral  nerve  lesion  and  possibly,  according  to  Leloir,  to  central 
complications. 

All  of  the  above-described  symptoms  vary  in  character  and  inten- 
sity. They  may  fail  altogether  or  be  so  slight  as  to  escape  attention. 
As  in  syphilis,  the  prodromes  are  by  no  means  constant  and  invariable. 
In  many  cases  the  patient  does  not  feel  any  indication  of  disorder 
until  after  the  appearance  of  the  eruption.  Their  significance  is  rarely 
recognized  or  rightly  interpreted  until  after  unmistakable  evidences 
of  the  disease  have  declared  themselves.  Even  in  countries  where 
leprosy  is  endemic  their  occurrence,  taken  in  connection  with  known 
exposure,  would  afford  presumptive  rather  than  positive  jiroof  of  their 
true  nature. 

It  will  be  more  convenient  to  study  separately  the  clinical  features 


SYMPTOMS  OF  TUBERCULAR  LEPROSY.  477 

of  the  two  principal  forms  of  leprosy,  since  the  determination  of  the 
morbid  process  to  the  tegumentary  system  in  the  one  form  and  to  the 
nervous  system  in  the  other  gives  rise  to  such  a  diversity  of  manifesta- 
tions that  the  clinical  pictures  presented  by  each  are  entirely  distinct. 


Tubercular  Leprosyo 

While- the  leprous  process  may  affect  various  tissues  and  organs 
of  the  body,  its  most  constant  and  characteristic  manifestations  are 
determined  towards  the  skin  and  mucous  membranes  of  the  upper  air 
passages.  The  clinical  picture  of  this  form  is  made  up  almost  exclu- 
sively of  the  changes  in  these  structures  caused  by  the  bacilli. 

The  eruptive  elements  consist  of  macular  lesions,  which  may  be 
simply  erythematous  or  pigmented,  infiltrations,  diffuse,  or  circum- 
scribed in  the  form  of  nodules,  succeeded  by  the  secondary  changes 
of  softening,  ulceration,  and  crusting,  or  fibroid  degeneration.  The 
cutaneous  manifestations  are  not,  as  a  rule,  continuously  present  in 
the  early  stage,  but  come  out  in  successive  crops.  At  first  they  are 
slight  and  transitory,  but  at  a  more  advanced  stage,  they  are  perma- 
nent and  impart  to  the  disease  a  peculiar  physiognomy  which  is 
pathognomonic  (see  Figs.  4  and  5).  Their  first  appearance  is  impor- 
tant as  marking  definitely  the  debut  of  the  disease,  and  they  often 
furnish  the  necessary  confirmation  of  the  diagnosis  which  was  fore- 
shadowed by  the  premonitory  symptoms  we  have  just  been  consider- 
ing. 

Period  op  Erythematous  Eruption. 

The  first  cutaneous  manifestations  occur  in  the  form  of  erythema- 
tous spots  or  patches,  which  are  sometimes  described  as  erythema 
leprosum  or  leprous  roseola.  These  spots  exhibit  a  great  variety  of 
asi^ect  in  their  size,  shajje,  color,  situation,  and  subsequent  evolution. 
They  are  usually  round  or  oval,  sometimes  irregular  in  outline,  from 
the  size  of  a  lentil  to  that  of  a  silver  dollar  or  the  palm  of  the  hand. 

The  surface  of  the  spots  is  as  a  rule  flat  and  smooth,  presenting  a 
greasy,  shining  appearance  without  perceptible  elevation  or  infiltration 
of  the  integument.  All  of  the  spots  do  not,  however,  correspond  to 
this  definition.  Later  they  may  be  perceptibly  elevated  aboye  the 
surrounding  skin,  with  a  slight  degree  of  infiltration  appreciable  to 
the  touch  or  even  to  the  eye. 

The  color  of  the  spots  has  been  variously  described  as  pinkish, 
reddish,  vinous  red,  reddish-brown,  coppery,  mahogany,  and  of  a 
sepia  or  iodine  tint.     These  qualificatives  indicate  a  wide  diversity 


478  MOBKOW — LEPROSY. 

in  the  color  characteristics  of  the  eruption  as  seen  by  different  ob- 
servers in  different  countries.  The  coloration  varies  according  to  the 
complexion  and  race  of  the  individual,  the  age  of  the  lesion,  and  cer- 
tain extraneous  conditions  such  as  exposure  to  the  sun,  the  wind,  etc. 

In  the  white  race  they  are  of  a  pinkish  or  crimson  color,  with  a 
redness  like  that  of  ordinary  erythema  which  deepens  into  a  dusky 
red  or  a  purplish  hue.  In  brown  and  dark  races  the  color  is  first  a 
mahogany  or  brownish-red,  assuming  later  a  dark  or  even  black  color- 
ation. In  both  races  the  color  is  apt  to  be  more  livid  in  de^jendent 
parts  of  the  body,  as  on  the  legs  and  feet. 

While  the  eruption  may  have  a  general  distribution  it  has  certain 
j>oints  of  predilection.  Most  commonly  it  appears  first  upon  the  ex- 
posed parts,  the  dorsum  of  the  feet,  about  the  ankles,  the  backs  of 
the  hands  and  wrists,  upon  the  forehead,  cheeks,  and  ears.  It  may 
appear  upon  the  buttocks,  thighs,  chest,  and  other  portions  of  the 
body,  but  rarely  upon  the  palms  of  the  hands  and  soles  of  the  feet. 
There  is  a  certain  degree  of  symmetry  observed  in  its  distribution. 

The  spots  may  increase  in  size,  apparently  like  the  spread  of  a 
drop  of  oil  on  a  sheet  of  paper.  The  earlier  spots  are  usually  transi- 
tory, disappearing  without  leaving  a  trace  or  only  a  slight  grayish 
pigmentation.  In  other  cases  they  may  require  weeks  or  months  for 
their  involution.  The  color  is  at  first  usually  more  pronounced  in 
the  centre,  fading  towards  the  circumference;  in  other  cases  their 
contours  are  sharply  defined.  After  a  while  the  redness  in  the  centre 
subsides,  giving  place  to  a  brownish  stain  or  only  a  slight  pigmenta- 
tion. Leloir  has  observed  an  ecchymotic  tint  similar  to  that  seen  after 
the  disappearance  of  certain  papular  erythemas. 

The  spots  are  exceedingly  variable  in  aspect,  like  that  of  erythema 
solare,  chloasma,  and  various  other  pigmentations  of  the  skin,  and 
they  have  little  diagnostic  significance.  Occasionally  spots  may  ap- 
I)ear  in  the  form  of  a  diffuse,  somewhat  erythematous  blush  or  red- 
dish tinge,  and  disappear  promptly  or  in  a  few  days  without  leaving 
a  trace. 

Garces,  in  describing  the  jjeculiarities  of  leprosy  in  Colombia, 
aajB  that  in  that  country  "  the  initial  exanthem  of  leprosy  is  almost 
always  of  the  urticarial  type.  Most  people  attribute  the  origin  of  the 
malady  to  cold  after  exposure,  allowing  the  sudden  cooling  of  the 
body  after  perspiration,  and  living  in  damp  rooms.  These  accidents 
are  followed  by  the  wheals  of  urticaria  which  are  the  starting-point 
of  leprosy." 

The  outbreak  of  the  erythema  is  frequently  preceded  or  accom- 
panied by  evidences  of  constitutional  disturbance,  such  as  chills  and 
fever,  a  general  feeling  of  lassitude,  malaise,  etc.     Local  sensations  of 


SYMPTOMS   OP   TTJBEECULAE  LEPROSY.  479 

pricking  or  itching  may  precede  or  attend  the  eruption  or  subjective 
sensations  may  be  entirely  absent.  Some  have  described  the  sensa- 
tion as  of  "  ants  walking  over  and  stinging  the  face"  (Hillis).  The 
patches  may  develop  insidiously,  without  the  knowledge  of  the  pa- 
tient and  unaccompanied  by  any  local  phenomena,  and  are  then  dis- 
covered by  chance. 

The  spots  are,  as  a  rule,  not  permanent,  but  they  may  appear  and 
disappear  a  number  of  times  before  the  establishment  of  the  charac- 
teristic tubercular  changes  without  leaving  any  trace  of  their  pre- 
vious existence.  The  earlier  eruptions  are  essentially  erythematous, 
the  coloration  is  affected  by  temperature  changes  and  disappears  tem- 
porarily on  pressure.  Later  the  patches  are  more  pigmented,  they 
pale  on  pressure,  but  the  coloration  is  not  entirely  effaced. 

Leloir  divides  the  lesions  of  this  stage  into  two  jDrincipal  groups, 
the  hi/percemic  si^ots  and  the  pigmented  spots  ;  in  the  latter  the  pigmen- 
tation is  secondary  to  the  hypersemia.  This  division  appears  to  in- 
troduce an  unnecessary  refinement  of  distinction,  as  the  pigmentation 
represents  an  evolutionary  change  which,  as  in  the  case  of  other  le- 
sions of  the  erythematous  type,  may  be  absent  or  present  according 
to  the  duration  and  intensity  of  the  capillary  congestion. 

With  each  congestive  attack  the  new  macules  become  larger  in 
extent  and  more  prominent  than  those  of  the  first  eruption.  Gradu- 
ally the  pigmentation  deepens  into  a  brownish-red  or  bluish-red  color, 
the  skin  becomes  thickened,  slightly  raised,  uneven,  and,  finally,  the 
seat  of  tubercular  infiltration. 

As  a  rule,  the  spots  are  not  anaesthetic ;  certainly  there  is  no  loss 
of  sensibility  at  all  comparable  to  what  characterizes  the  spots  of 
anaesthetic  leprosy.  Exceptionally  there  may  be  a  very  ajjpreciable 
loss  of  sensation  in  patches  which  have  become  thickened  and  which 
have  existed  for  a  long  time.  Disassociation  of  the  different  modes  of 
sensation  is  rarely  observed.  While  the  patches,  as  a  rule,  are  rarely 
universal,  there  is  often  to  be  observed  a  marked  change  in  the  colora- 
tion and  texture  of  the  entire  skin.  In  white  races  it  may  become  dry 
and  yellowish  or  bronzed — a  tint  which  has  been  compared  by  Eayer 
to  the  skin  of  the  mulatto. 

During  months  and  years  the  disease  may  remain  practically 
stationary,  the  clinical  picture  being  diversified  at  times  by  the  dis- 
appearance of  old  spots  and  the  appearance  of  new  ones,  and  by  their 
gradual  transformation  into  the  bluish-red  infiltrated  patches,  which 
remain  more  or  less  permanent. 


480 


MORROW — LEPROSY. 


Period  of  Eruption  of  Tubercles. 


After  a  time  the  pigmeuted  patches,  instead  of  undergoing  invohi- 
tiou,  remain  jiersistent,  tlie  skin  becomes  slighty  thickened  and  swol- 
len and  the  seat  of  tnl)ercular  infil- 
trations, which  appear  in  the  form 
of  small  jiea-sized  or  larger  nodules, 
which  may  remain  stationary  or 
rajjidly  enlarge.  The  tubercles 
may,  however,  develop  uijon  new 
surfaces  which  have  not  been  the 
site  of  preceding  pigment  changes. 
Exceptiouallv  the}^  may  develoj) 
coincidently  with  the  first  erythem- 
atous eruption,  constituting  the  pre- 
cocious tubercular  stage. 

The  eruption  of  tubercles  is 
almost  always  preceded  by  febrile 
symjitoms  and  other  evidences  of 
constitutional  disturbance,  with 
more  or  less  hypersemia  and  oedema 
of  the  pigmeuted  patches.  At  a 
more  advanced  stage  the  tubercular 
outbreak  may  be  attended  by  no 
appreciable  rise  of  temperature. 

The  tubercles  exhibit  great  diver- 
sity of  aspect  in  form,  volume,  con- 
sistence, coloration,  situation,  and 
mode  of  evolution.  They  may  be 
dermic  or  hypodermic  in  their  situa- 
tion. They  usuallj^  appear  in  the 
form  of  small  nodides,  the  size  of  a 
shot  or  a  pea,  and  they  may  attain 
the  size  of  a  cherr\',  hazelnut,  or 
pigeon's  egg,  or  they  may  form  large 
tubercular  masses  from  the  fusion 
of  contiguous  tubercles. 
The  coloration  of  the  tubercles  varies  in  different  races.  Ordinar- 
ily they  are  of  the  same  color  as  the  pigmented  skin  upon  which  thej^ 
develop.  In  dark  races  they  are  pinkish,  brownish-red,  some  pre- 
senting a  mahogany  tint  or  hue  like  that  of  an  iodine  stain.  In  white 
races  they  are  pale  or  yellowish  upon  their  first  appearance,  or  they 


Fig.  2. 


SYMPTOMS  OF  TUBERCULAR  LEPROSY.  481 

may  on  growing  older  show  a  reddish-brown  or  bluish-red  color,  de- 
pending upon  the  region  of  the  skin  upon  which  they  develop.  On 
the  extremities  they  are  darker  and  more  elevated  than  on  the  trunk. 

In  consistence  the  tubercle  is  at  first  comparatively  soft  and  elastic, 
later  it  grows  firmer  and  harder.  The  lesions  are  softer  upon  the 
trunk  than  ujDon  the  face  and  extremities.  The  surface  is  smooth  as 
if  oiled,  and  sometimes  the  tense  epidermis  breaks  at  the  summit  and 
there  may  be  a  branny  or  psoriasiform  desquamation.  They  are  at 
first  painful  on  pressure,  but  later  they  become  indolent  and  abso- 
lutely insensitive,  probably  because  of  pressure  ui)on  and  degenera- 
tion of  the  compressed  nerves. 

The  seats  of  predilection  for  the  tubercles  are  the  facial  mask,  the 
forehead,  especially  the  supraorbital  region,  the  cheeks,  chin,  nose,  and 
lips,  the  lobes  of  the  ears,  the  dorsal  surfaces  of  the  hands  and  feet, 
the  ankles,  forearms,  and  wrists,  the  outer  aspect  of  the  thighs,  and  the 
buttocks.  The  primary  eruption  almost  invariably  appears  upon  the 
forehead  or  cheek,  the  anterior  aspect  of  the  forearms  or  the  outside 
of  the  thigh ;  Imj^ey  says  in  his  experience  the  first  tubercle  is  com- 
monly seen  at  the  inner  border  of  the  supraorbital  ridge.  They  may 
develop  upon  any  portion  of  the  body  except  the  hair}^  scalp,  which 
is  almost  always  exempt.  They  are  rarely  seen  over  the  elbow-  or 
knee-joints  or  upon  the  j)alms  and  soles,  in  which  situation  they  are 
flattened  rather  than  prominent.  As  a  rule  they  are  flatter  on  the 
trunk  from  pressure  of  the  clothing.  They  may  appear  upon  the 
genital  parts,  the  scrotum,  prepuce,  around  the  anus  or  vagina,  and 
exceptionally  upon  the  glans  penis. 

Most  authorities  aflirm  that  the  tubercles  never  appear  upon  the 
glans  penis.  I  have,  however,  a  photograph  of  a  Chinaman,  whom 
I  examined  in  San  Francisco,  which  shows  characteristic  tubercles 
on  the  glans  (Fig.  2). 

In  the  earlier  stage  the  tubercles  are  small,  resembling  the  papules 
of  syphilis,  the  tubercles  of  lupus  vulgaris,  of  acne  indurata,  or  of 
sycosis.  The  remarkable  resemblance  of  the  case  illustrated  in  Fig. 
3  to  syphilis  will  be  noted  at  a  glance. 

The  boy,  H— —  A ,  a  native  of  Key  West,  Florida,  is  14  years 

old ;  he  has  two  sisters  and  a  brother,  all  healthy ;  the  mother  and 
father,  natives  of  the  West  Indies,  both  enjoy  good  health ;  one  uncle 
has  been  a  sufferer  from  a  chronic  skin  affection  for  a  number  of  years, 
said  to  be  an  eczema.  Four  years  ago  he  had  an  attack  of  measles. 
Upon  regaining  his  health,  it  was  observed  that  he  had  a  "rash," 
which  did  not  fade,  as  was  anticipated  the  skin  trouble  would.  His 
general  health,  however,  seemed  good,  but  during  the  hot  weather 
his  skin  would  assume  a  peculiar  hue,  and  in  jjlaces  small  elevations 
would  appear,  all  fading  when  a  cool  day  came.  From  what  I  have 
Vol.  XVIII.— 31 


482 


MORROW — LEPKOSY. 


beeu  able  to  glean,  the  boy  had  been  most  thoroughly  treated  for 
syphilis ;  he  had  beeu  to  school,  aud  led  his  usual  life  uutil  the  fall  of 
1893,  wheu  he  was  sent  to  New  York  for  advice  as  to  the  nature  of 
his  ailment.     At  the  time  I  first  saw  him  his  condition  was  about  as 


Fig.  3.— Tubercular  Leprosy  (Early  Stage). 

follows :  Skin  sallow,  tongue  coated ;  pulse  not  so  full  and  strong  as 
one  would  expect  to  find  in  a  boy  of  his  age— accounted  for  when  his 
heart  was  listened  to,  as  that  organ  was  weak,  but  no  murmurs  could 
be  found.  His  appetite  was  poor,  meat  being  sought  for  and  vege- 
tables avoided  by  him.  He  could  not  stand  any  fatigue,  being  unable 
to  walk  any  distance  or  perform  any  laborious  tasks.  The  tubercle.s, 
more  prominent  on  the  face  than  elsewhere,  were  also  present  on  his 
extremities.     His  bodv  was  free  from  these  neoplasms,  but  there  were 


SYMPTOMS  OF  TUBERCULAR  LEPROSY.  483 

areas  wliicli  seemed  to  have  lost  the  pigmentation,  or  the  pigment 
was  increased  in  some  places  and  faded  in  others.  No  anaesthetic 
areas  could  be  found.  In  his  mouth,  extending  from  midway  of  the 
hard  palate  to  well  on  the  soft  part  of  the  jialate,  was  an  ulceration 
with  elevated  borders.  It  was  probablv  one  and  a  half  inches  in 
length  by  one-half  to  three-quarters  of  an  inch  wide.  He  complained 
of  no  pain  or  inconvenience  from  this  lesion,  which  improved  greatly 
after  he  was  placed  upon  nus  vomica.  An  ulcerated  condition  existed 
on  his  right  foot,  just  back  of  the  great  toe;  also  a  spot  on  the  inner 
side  of  each  thigh.  The  ulceration  on  the  foot  healed  kindly,  but 
when  the  boy  was  last  seen  the  two  other  ulcers  were  far  from  healing. 

The  boy  was  taken  to  the  Hospital  for  Coutagious  Disease,  where 
he  remained  until  his  death  in  January,  1898.  I  am  indebted  to  Dr. 
J.  M.  Winfield,  of  Brooklyn,  for  further  notes  of  the  case. 

The  tubercular  areas  (face,  neck,  ears,  arm,  hands,  legs,  and  feet) 
gradually  became  more  pronounced,  and  the  ulcerations  were  deep. 
Occasionally  the  skin  would  clear  up,  and  the  boy  gain  strength;  he 
grew  very  tall,  and  was  exceedingly  sensitive  to  observation.  His 
throat  symptoms,  which  were  present  from  the  start,  gradually  grew 
worse,  and  at  times  great  difficulty  was  experienced  in  swallowing. 
Once  or  twice  the  swelling  of  the  glottis  seriously  interfered  with  res- 
piration. This  condition  of  affairs  continued,  each  day  the  patient 
growing  more  and  more  anaemic  and  emaciated  until  he  was  finally 
obliged  to  keep  his  bed.      His  death  occurred  from  suffocation. 

The  pharynx,  epiglottis,  and  trachea  were  found  to  be  thickened 
and  ulcerated.  There  were  never  any  sensory  disturbances  or  patches 
of  anaesthesia. 

As  the  tubercles  grow  older,  or  as  they  develoiD  at  a  later  stage,  they 
are  larger  and  more  voluminous  and  exhibit  a  more  pronounced  colora- 
tion. Sometimes  they  appear  as  small  firm  nodules  closely  set  to- 
gether, the  spaces  between  them  being  accentuated  as  furrows.  This 
massing  of  the  tubercles  -is  especially  Sfien  about  the  supraorbital 
ridges,  and  upon  the  extensor  surfaces  of  the  arms  and  legs.  The 
tubercles  in  this  location,  while  they  ma}'  be  closely  aggregated,  are 
usually  well  defined  and  sharjjly  distinct  from  each  other. 

Instead  of  being  isolated,  the  nodules  may  become  confluent  and 
appear  in  the  form  of  large  plaques  of  thickened  skin  of  variable  size 
and  extent  {Jepromes  en  nappe) .  These  j)laques  are  somewhat  elevated, 
bluish,  livid,  or  violaceous  in  color  or  even  brownish  or  black  {mor- 
phoea  nigra  of  the  ancient  writers).  In  consistence  they  are  firm,  and 
Deloir  compares  the  plaque  to  a  piece  of  cardboard  mortised  in  the 
skin.  In  other  cases,  the  infiltration  may  become  thick  and  denser, 
like  a  hard  oedema  of  the  skin  and  subcutaneous  tissues ;  Bazin  has 
termed  this  condition  leprous  scleroderma. 

The  surface  of  the  plaque  is  usually  mammillated,  rough,  and  un- 


484  MORROW — LEPROSY. 

even,  and  sometimes  the  seat  of  epidermic  desquamation.  Tlie 
j)laques  varv  in  size  from  tLat  of  the  palm  to  extensive  infiltrations 
covering  the  entire  surface  of  the  limb.  They  are  usually  sharply 
demarcated;  at  other  times  they  blend  almost  insensibly  with  the 
sound  skin.  They  may  exist  for  years  without  undergoing  marked 
changes.  In  one  case,  which  I  had  under  obsen'ation  for  several 
years,  the  plaques  on  the  extensor  surfaces  of  the  arms  and  thighs 
remained  unchanged.  Campana  has  shown  that  there  is  usually  an 
elevation  of  temperature,  from  one  to  two  degrees,  to  be  observed  over 
these  plaques,  which  is  sometimes  succeeded  by  a  subnormal  temper- 
ature. 

The  disease  extends  by  the  invasion  of  new  areas  of  previously 
unaffected  skin  and  the  development  of  new  tubercles  or  plaques  in 
the  neighborhood  of  existing  tubercles.  In  many  cases  there  is  a 
gradual  increase  in  the  sizo  or  volume  of  the  tubercles.  In  other 
cases  there  are  repeated  congestive  attacks  which  are  synchronous 
with  the  multiplication  of  the  bacilli,  and,  since  the  growth  of  the 
bacilli  does  not  take  place  at  a  uniform  rate,  these  attacks  or  exacer- 
bations occur  at  irregular  intervals,  often  accompanied  by  fever  and 
general  symptoms.  They  commonly  coincide  with  or  may  be  con- 
secutive to  softening  and  resorption  of  numbers  of   the  tubercles. 

These  exacerbations  may  simulate  an  attack  of  erysipelas  or  of 
erythema  nodosum,  and,  according  to  Leloir,  they  are  due  to  resorption 
of  leprous  virus  by  the  lymphatics  and  its  extension  along  these  chan- 
nels. Evidence  of  this,  he  claims,  may  be  found  in  the  fact  that 
there  are  often  observed  painful  swellings  of  the  neighboring  lym- 
phatic ganglia  and  ribbon-like  prolongations  of  lymphangitis.  Xot 
infrequently  there  are  rheumatoid  pains  and  painful  swellings  in  the 
joints  in  connection  with  these  exacerbations. 

At  this  period  the  skin  of  the  face  becomes  tumefied  with  a  shiny, 
glazed,  discolored  appearance,  the  backs  of  the  hands  and  feet  are 
often  puffy  and  swollen  with  a  diffuse  infiltration,  especially  marked 
over  the  dorsal  surface  of  the  first  and  second  phalanges,  giving  the 
fingers  a  fusiform  appearance.  The  dorsal  surfaces  of  the  feet  may 
be  similarly  affected.  Frequently  the  skin  about  the  ankle  and  leg 
becomes  thickened  and  indurated  and  the  seat  of  a  hard,  oedematous 
swelling,  which  may  be  covered  with  large  imbricated  scales  with 
papillomatous  proliferations.  This  pachydermatous  condition  pre- 
sents a  striking  resemblance  to  that  of  elephantiasis  arabum. 

It  is  to  be  remarked  that  the  process  of  ulceration  in  old  tubercles 
occurs  coincidentally  with  the  development  of  new  ones. 

Daniellsen  and  Boeck  have  observed  that  congestive  attacks  which 
precede  or  accompany  the  ai>pearanceof  new  tubercles  are  often  syn- 


SYMPTOMS   OF   TUBEECULAR  LEPROSY. 


485 


chronous  with  tlie  breaking  down  and  resorption  of  old  ones.  This 
process  is  usnalh"  accompanied  by  fever  and  general  phenomena  of 
systemic  disturbance  which  disappear  spontaneously. 

The  new  tubercles  remain  stationary  or  develop  until,  with  a  new 
congestive  attack,  the}'  undergo  the  same  evolutionary  changes.  Ac- 
cording to  Leloir  the 
skin  which  surrounds 
the  tubercles  becomes 
red  and  there  develop 
localized  tumefactions, 
resembling  those  of 
erythema  nodosum, 
which  are  gradually 
transformed  into  new 
leprous  tubercles,  at 
the  same  time  aug- 
menting the  volume  of 
the  preexisting  tuber- 
cles around  which  they 
are  developed. 

In  countries  where 
leprosy  is  endemic,  it 
has  been  observed  that 
the  tubercles  become 
larger  and  more 
marked  for  three  or 
four  years,  when  they 
begin  to  break  down 
and  ulcerate. 

The  evolution  of 
the  tubercles  is  not 
sufficienth'  regular  to 
admit  of  chronological 

classification.  Thoir  most  marked  and  characteristic  development 
occurs  upon  the  face,  and  gives  that  peculiar  aspect  to  the  individual 
which  has  been  denominated  leontiasis,  and  which  is  pathognomonic 
of  the  disease.     (See  Figs.  4  and  5.) 

In  the  advanced  stage  the  integument  of  the  face  becomes  infil- 
trated with  tubercular  nodules  or  masses  which  exaggerate  the  natural 
lines  or  furrows  of  the  skin.  The  supraorbital  regions  are  studded 
with  the  tubercles,  most  marked  towards  the  internal  border,  and  form 
protuberant  masses  separated  by  vertical  furrows,  which  intersect  the 
horizontal  furrows,  forming  lobulated  masses.     The  cheeks,  especially 


Fig.  4.— Typical  Facies  of  Tubercular  Leprosy.  (From  Mor- 
row's "  System  of  Geni,.o-Urinary  Diseases,  Syphilology, 
and  Dermatology.") 


486 


MORROW — LEPROSY. 


over  the  malar  i)romineuces,  are  enormously  tiimefied  aud  uneven  with 
tubercles.  The  lii)S  are  swollen  and  everted,  the  ahe  of  the  nose 
thickened  aud  broadened,  the  chin  is  enlarged  and  covered  with  bossy 
l)rotuberanc'es,  giving  it  a  S([uare  appearance,  the  lobes  of  the  ears  are 
enlarged,  hanging  down  in  Habby  pendulous  masses.  These,  with  the 
loss  of  the  eyebrows  and  lashes,  the  conjunctival  and  corneal  lesions, 

are  elements  in  a  pic- 
ture of  hideous  deform- 
ity which  once  seen  can 
always  be  recognized 
as  pathognomonic. 

The  course  of  the 
tubercles  and  diffuse 
infiltration  may  re- 
main stationary  and 
practically  no  change 
take  place,  except  in 
size,  for  months  or 
years,  the  surface  des- 
(luamating  and  the 
color  changing  into  a 
CO  Pinery,  dark  brown, 
or  livid  tint. 

The  tubercles  may 
undergo  gradual  re- 
sorption or  become 
transformed  by  a  proc- 
ess of  fibrous  indura- 
tion into  small  masses, 
which  persist  indefi- 
nitely without  further 
change,  or  they  may 
take  on  a  keloidal 
character. 
The  disappearance  of  one  group  is  succeeded  by  another  in  the 
same  or  new  regions  at  variable  intervals. 

Lymphatic  Gaiu/Jia. — Implication  of  the  lymphatic  ganglia  may 
begin  at  an  early  stage  of  leprosy.  Swelling  of  the  glands  is  most 
pronounced  in  the  inguinal  region.  Usuall}'  the  swelling  increases 
with  each  congestive  attack,  and  the  glands  may  attain  the  volume  of 
a  nut  or  even  a  goose  egg.  The  cervical  and  axillary  ganglia  may 
also  attain  to  large  a  size.  The  swellings  of  the  submaxillary  and  sub- 
lingual glands  may  be  so  pronounced  as  to  impede  the  movements  of 


Fig.  5.— Typical  Facies  of  Tubercular  Leprosy.  (From  Mor- 
row's "  System  of  Geuito-Urinary  Diseases,  Syphilology, 
and  Dermatology.") 


SYMPTOMS  OP  TUBEECULAR  LEPROSY.  487 

tlie  jaws  and  even  interfere  with  tlie  process  of  deglutition.  All  of 
the  glands  of  the  body  accessible  to  the  touch  may  be  found  enlarged, 
the  popKteal,  epitrochlear,  etc.  It  is  probable  that  there  is  coinci- 
dent enlargement  of  the  mesenteric  glands,  as  has  been  demonstrated 
by  autopsy  in  many  cases.  There  is  a  hyperplasia  of  the  connective 
tissue. 

The  glands  rarely  soften  and  ulcerate,  but  in  the  final  stage  there 
may  be  found  fistulous  tracts  communicating  with  the  ganglia  from 
which  a  large  quantity  of  thick  matter  escapes.  Leloir  believes  that 
the  lymphatic  ganglia  are  veritable  sources  of  the  leprous  virus,  con- 
stituting centres  of  autoinfection,  and  that  their  condition  is  always 
in  direct  relation  to  the  course  of  the  disease.  In  the  early  stages 
they  are  but  slightly  swollen,  but  later,  with  the  multiplication  and 
accumulation  of  the  bacilli,  they  become  large  and  painful. 

During  this  entire  period  there  are  to  be  observed  certain  changes 
in  the  glandular  portions  and  appendages  of  the  skin,  and  sensory 
disorders  more  or  less  pronounced. 

The  sebaceous  and  sweat  glands  are  disturbed  in  their  function  at 
an  early  period  of  the  disease.  The  alterations  of  the  glandular 
apparatus  are  often  noticeable  during  the  erythematous  sfege,  but 
become  more  pronounced  with  the  progress  of  the  disease.  There  is 
generally  an  increase  in  their  functional  activity,  expressed  by  hyper- 
secretion, which  is  followed  by  diminution  or  arrest,  which  may  be 
general  or  localized  in  certain  areas. 

The  exaggeration  in  the  function  of  the  sebaceous  glands  in  the 
early  stage  gives  the  skin  a  characteristic  shiny  appearance,  as  if  it 
had  been  rubbed  with  oil.  Later  the  sweat  disappears  from  the  af- 
fected regions  and  sometimes  is  suppressed  over  the  entire  body,  and 
the  skin  becomes  dry  and  harsh  from  the  disappearance  of  the  glan- 
dular secretions. 

Hair  Follicles. — The  leprous  process  usually  aifects  the  pilous 
elements  of  the  skin  in  the  most  destructive  manner.  The  alopecia 
is  first  manifest  in  the  fragility,  thinning,  and  falling  of  the  hair,  and 
later  in  complete  loss  of  the  hair  in  certain  regions.  The  falling  out 
of  the  hair  is,  as  a  rule,  confined  to  the  localities  affected  by  the  erup- 
tion and  is  absent  over  the  spots  and  present  in  the  intervals  between 
them.  Usually  the  first  to  suffer  are  the  eyebrows,  the  loss  of  which 
constitutes  one  of  the  most  characteristic  features  of  tubercular  lep- 
rosy, and  is  valuable  from  a  diagnostic  point  of  view.  The  alo- 
pecia also  affects  the  beard,  the  nostrils,  and  other  pilous  portions  of 
the  body  which  are  the  seats  of  tubercular  infiltrations.  Upon  the 
face  the  conservation  of  the  hairs  in  the  intervals  between  the  leprous 
infiltrations  give  the  beard  a  sort  of  tufted  appearance  (Fig.  4). 


488  MORROW — LEPROSY. 

The  liairy  scalp  enjoys  a  surjirisiuf^  immunity  from  the  encroach- 
ments of  the  bacilli.  It  is  not  uncommon  to  see  a  leper  with  a  fine 
growth  of  hair  on  the  head,  while  the  hair  has  almost  disappeared 
from  the  rest  of  the  body.  On  the  general  surface  of  the  body  the 
hairs  suffer  from  a  pronounced  inanition  before  gradually  disappear- 
ing, becoming  dried,  atrophic,  and  easily  broken. 

The  development  of  leprosy  before  puberty  exercises  an  inhibitorj'^ 
effect  upon  the  growth  of  the  hair  over  the  entire  surface  of  the  body. 
There  is  commonly  observed  an  arrest  of  development  of  the  hair  in 
the  axillary,  pubic,  and  facial  regions ;  the  eyebrows  and  bodj'  hair 
fall  out  subsequently,  leaving  the  body  entirely  glabrous. 

Sensory  Disorders. — The  disorders  of  sensibility  are  not  constant 
or  characteristic  features  of  tubercular  leprosy.  In  many  cases  even  of 
extensive  distribution  of  tubercular  lesions  sensation  may  be  preserved 
in  complete  integritv.  Certain  of  the  lesions  may  be  at  first  hyper- 
sesthetic  succeeded  by  anaesthesia,  and  in  rare  cases  there  may  be  dis- 
association  of  the  modes  of  sensibility,  as  in  anaesthetic  leprosy. 

It  is  probable  that  the  anaesthesia  of  the  tubercles  and  surrounding 
skin  is  caused  by  pressure  upon  the  terminal  filaments  of  the  cutaneous 
nerves,  which  pass  into  the  tubercle,  and  the  cuticle  becomes  anaes- 
thetic from  paralysis.  It  has  been  observed  that  sensibility  may 
return  in  parts  that  have  been  anaesthetic,  which  would  indicate  that 
the  phenomenon  is  caused  by  comj^ression  rather  than  by  degenera- 
tion or  destruction  of  the  peripheral  nerves.  In  general  it  may  be 
said  that  the  older  the  lesion  the  more  accentuated  the  loss  of  sensa- 
tion. 

Leprosy  of  the  Mucous  Membranes. 

The  changes  in  the  mucous  membranes  caused  bj^  leprosj^  have 
always  been  regarded  as  constituting  one  of  the  most  characteristic 
features  of  the  disease,  but  the  chronological  order  in  which  these 
changes  take  place  has  not  until  recently  been  recognized.  The 
general  consensus  of  opinion  has  been  that  morbid  alterations  in  the 
mucosa  never  occur  before  the  skin  is  affected ;  while  most  writers 
assign  the  date  of  their  development  to  a  i:)eriod  long  subsequent  to 
the  appearance  of  the  cutaneous  manifestations. 

In  an  article  on  "Leprosy,"  written  several  years  ago  {loc.  cit.) 
the  present  writer  expressed  his  views  as  follows:  "Contrary  to 
what  is  usually  taught,  I  believe  that  the  first  manifestations  of 
leprosy  are,  in  the  majority  of  cases,  determined  toward  the  mucous 
membranes  of  the  pharynx  and  upper  air  passages.  Few  of  our  mod- 
ern authorities  seem  to  recognize  the  precocity  of  these  manifesta- 
tions, although  Hillis  remarks  that  in  tubercular  lejn-osy  the  first 


LEPEOSY   OF   THE   MUCOUS   jVIEMBKANES.  489 

tliroat  manifestatious  occur  during  tlie  febrile  attack.  According  to 
niv  observation,  alteration  of  tlie  voice,  betrayed  by  a  slightly  husky 
or  rough  phonation,  rhinitis,  with  an  abnormally  free  nasal  secre- 
tion, sometimes  epistaxis,  and  an  increase  in  the  salivary  secretions 
are  among  the  earliest  signs  of  leprosy. "  "  At  a  more  advanced  stage, 
when  there  are  leprous  deposits  in  the  mucous  surfaces  with  involve- 
ment of  the  cartilages  and  bones,  the  characteristic,  harsh,  raucous 
voice  and  the  difficult,  sniffling  respiration  from  obstruction  of  the 
nostrils  are  almost  invariable  concomitants." 

It  has  usually  been  asserted  that  in  anaesthetic  leprosy  the  mucous 
membranes  of  the  upper  air  passages  are  not  implicated.  In  a  num- 
ber of  cases  collected  by  Gluck,  he  found  the  mucosa  of  the  lips 
affected  four  times,  the  tongue  twice,  palate  and  throat  three  times, 
larynx  four  times,  and  nose  fifteen  times.  Undoubtedly  there  are 
many  cases  of  anaesthetic  leprosy  in  which  symptomatic  manifesta- 
tions are  present  when  the  existence  of  specific  lesions  in  this  locality 
cannot  be  demonstrated. 

A  patient  in  the  early  stage  of  anaesthetic  leprosy,  now  under  my  ob- 
servation, cannot  go  from  a  warm  room  into  the  cold  air  without  liabili- 
ty to  a  copious  nasal  secretion  compelling  her  to  use  a  handkerchief 
almost  continually.  In  this  case  there  are  no  visible  leprous  changes 
in  the  nose,  and  the  phenomenon  is  probably  due  to  the  action  of  the 
bacilli  upon  the  vasomotor  nerves  of  the  pituitary  meinbrane  robbing 
it  of  their  protecting  power,  so  thau  it  responds  to  the  action  of  the 
cold  air  by  an  abnormal  secretion.  The  increased  salivary  secretion 
may  be  caused  by  reflex  irritation  of  the  salivar.v  glands.  Jeanselme 
and  Laurens  claim  that  leprous  coryza  is  not  necessarily-  dependent 
upon  previous  infiltration,  and  that  the  coryza  becomes  attenuated  or 
disappears  spontaneously  when  the  leprosy  tends  to  become  anaes- 
thetic. 

According  to  Hillis,  coincidenth-  with  the  appearance  of  tubercles 
on  the  cutaneous  surface  the  mucous  membranes  of  the  mouth,  the 
pillars  of  the  fauces,  the  uvula,  and  the  tongue  may  become  studded 
with  pinhead-sized  papules.  It  will  be  more  convenient  to  study  the 
mucous-membrane  manifestations  of  the  different  regions  of  the  up- 
per air  and  food  passages  sexjarately. 

The  Nasal  Mucous  Meriibranes. — First  in  point  of  frequency,  as 
well  as  in  importance,  are  the  changes  in  the  nasal  mucous  membranes 
caused  by  leprosy.  The  investigations  of  Sticker  and  of  Jeanselme 
and  Laurens,  to  which  reference  has  been  elsewhere  made,  throw 
considerable  light  upon  the  pathological  alterations  of  the  nasal  mu- 
cosa. A  unique  importance  has  been  given  to  lepros\'  of  the  mucous 
membrane  by  the  demonstration  of  the  precocity  of  its  manifesta- 


490  MORKOW — LEPROSY. 

tion.  These  authorities  state  that  leprous  coryza,  which  may  simu- 
late ordinaiy  corvza,  constitutes  the  first  exterior  manifestation  of 
the  disease  in  a  large  proportion  of  all  cases.  In  lepra  nervosa  it 
shows  a  tendency  to  disappear  spontaneously.  In  the  tubercular 
form,  on  the  contrary,  it  undergoes  exacerbations  from  time  to  time, 
and  these  coincide  with  the  cutaneous  efflorescences,  the  rhinitis  be- 
ing often  cauesed  by  leprous  infiltrations  in  the  nasal  mucous  mem- 
brane. 

Among  the  most  important  symptoms  of  the  initial  stage  is  epi- 
staxis.  This  may  have  the  same  importance  as  a  revealing  sign  of 
leprosy  as  the  hcBmoj^tysis  which  is  premonitory  of  pulmonary  tuber- 
culosis. The  epistaxis  may  be  quite  abundant  and  accompanied  with 
congestive  jihenomena,  vertigo,  etc.,  in  the  initial  stage,  but  later 
becomes  reduced  to  the  loss  of  a  few  drops  of  blood  when  the  patient 
makes  an  effort  to  expel  the  crusts  which  obstruct  the  nostrils,  and 
later  ceases  altogether.  In  all  these  cases  there  is  a  marked  ten- 
dency to  erosion  and  superficial  iilceration  of  the  pituitary  mem- 
brane, which  becomes  covered  with  thick  adherent  crusts  formed  by 
the  abundant  mucous  or  sanguinolent  secretion. 

As  the  disease  advances  the  ulcers,  which  are  usually  situated  in 
the  septum,  become  deeper  and  more  extensive,  and  finally  perforate 
the  cartilaginous  septum.  This  perforation  may  be  circumscribed 
and  of  limited  extent,  circular  or  elliptical  in  form,  readily  permitting 
the  introduction  of  a  j)robe  from  one  nostril  into  the  other.  More 
often  the  septum  is  destroyed  in  its  totality-  with,  or  more  frequently 
without,  involvement  of  the  bonj"  framework  of  the  nose.  The  nose 
becomes  deformed,  sunken,  flattened  out,  the  lobules  almost  touching 
the  upper  lij)  and  separated  from  it  only  by  a  slight  gutter.  The 
destruction  of  the  cartilaginous  septum  occurs  very  insidiously  and 
without  the  knowledge  of  the  i)atieut.  It  would  seem  to  take  place 
by  a  process  of  interstitial  absorption,  since  expulsion  of  cartilaginous 
sequestra  has  not  been  observed. 

The  rhinoscopic  picture  of  the  pathological  alterations  which  ex- 
plains the  functional  troubles  and  the  mechanism  of  the  production 
of  the  characteristic  deformities  of  the  nose  is  thus  given  by  Jean- 
selme  and  Laurens : 

"  Immediately  above  the  vestibule,  the  skin  of  which  is  almost  al- 
ways intact,  the  mucous  membrane  is  red,  turgid,  and  furrowed  with 
tortuous  and  distended  capillaries.  This  congestion  attains  its  maxi- 
mum at  the  anterior  and  inferior  x^ortion  of  the  septum.  At  this 
point  the  mucous  membrane  is  often  covered  with  small  brownish 
crusts — vestiges  of  recent  hemorrhages  or  of  erosions  more  or  less 
extensive  lined  with  miicopus.      The  slightest  touch  of  the  probe 


LEPEOSY  OF  THE  MUCOUS  MEMBRANES.  491 

over  this  liemorrhagic  zone  provokes  a  sanguinolent  discharge.  The 
mucous  covering  of  the  entire  inferior  segment  of  the  septum  is  ordi- 
narily quite  thickened  and  its  consistence  sensibly  diminished.  Some- 
times, also,  the  pituitary  membrane  which  covers  the  inferior  turbi- 
nated bones  is  infiltrated,  soft,  and  depressible.  In  one  of  our  patients 
the  middle  turbinated  was  voluminous,  of  a  blanched  color,  and  was 
covered  with  a  multitude  of  small  congested  points,  of  an  almost 
ecchymotic  redness." 

At  a  more  advanced  period  the  septum  is  easily  depressed  by  the 
probe,  the  consistence  of  the  cartilage  is  notably  diminished,  and  per- 
foration takes  place.  "  When  the  perforation  is  recent  the  free  border 
is  thick,  callous,  and  bleeds  easily.  When  it  has  existed  for  some 
time,  the  mucous  membrane  is  thinned,  pale,  and  cicatricial.  These 
two  aspects  may  be  observed  in  the  same  perforation,  one  portion  of 
the  circumference  being  already  cicatrized,  while  the  other  is  still  in 
an  ulcerous  condition — one  never  finds  the  cartilage  denuded.  When 
the  rhinitis  disappears  ^the  membrane  which  covers  the  turbinated 
bones  may  undergo  a  certain  degree  of  atrophy,  resulting  in  a  consid- 
erable gaping  of  the  nasal  cavities,  and  bringing  into  view  quite  a 
large  surface  of  the  posterior  pharyngeal  wall." 

In  addition  to  the  changes  caused  by  leprous  rhinitis  there  is 
sometimes  observed  a  deposit  of  leprous  tubercles  which  may  be  dis- 
tributed over  the  lower  turbinate,  the  sei^tum,  the  floor,  or  vestibule 
of  the  nares.  Thej^  are  of  variable  number,  flattened,  lenticular,  firm 
to  the  touch,  and  contrast  by  their  grayish-white  or  pinkish  color 
with  the  deep  red  of  the  mucous  membrane.  Ordinarily  isolated, 
they  may  become  confluent  and  form  a  continuous  opaline  and  mam- 
mellated  nappe.     The  vibrissse  fall  out  at  an  early  stage. 

All  authorities  agree  that  notwithstanding  the  destructive  charac- 
ters of  the  nasal  lesions  the  sense  of  odor  persists  intact  with  scarcely 
notable  modifications. 

Sensation  is  often  notably  diminished  or  entirely  abolished  over 
the  affected  portions.  Thus  ic  may  be  entirely  lost  in  the  membrane 
covering  the  septum — so  that  one  may  freely  cauterize  the  region  of 
the  septum  without  provoking  pain,  while  the  skin  of  the  vestibule 
of  the  nares  is  normally  sensitive.  In  certain  cases  anaesthesia  may 
be  entirely  independent  of  any  eruptive  manifestation. 

The  Mucous  Membrane  of  the  Mouth  and  Throat. — Three-fourths 
of  all  cases  of  tubercular  leprosy  show  mouth  and  throat  lesions ;  in 
the  anaesthetic  form  the  proportion  is  much  smaller. 

The  mouth  and  mucosa  of  the  lips  are  often  affected.  The  lep- 
rous infiltration  causes  a  general  thickening,  with  a  superficial  pro- 
duction of  nodules.     These  may  excoriate  or  ulcerate,  and  healing 


492  MORROW— LEPROSY. 

witli  scars  results.  The  iufiltration  is  accompanied  by  a  tendency 
to  form  rbagades  which  are  deep,  painful,  and  bleed  readil}'.  Ulcers 
are  especiallj'^  prone  to  occur  on  the  free  border  of  the  lips  and  in  severe 
cases  healing  is  followed  bj''  stenoses  and  entropion  of  the  mouth. 

Ginns. — The  gums  are  affected  rarelj'  and  late.  When  they  do 
not  actively  participate  they  are  hard,  pale,  and  smooth.  When  they 
are  activel}^  involved  they  are  swollen  and  eroded  on  the  edges ;  re- 
traction follows. 

Cheeks. — The  mucosa  of  the  cheeks  is  involved  even  more  rarely 
than  the  gums.  The  appearance  when  not  actively  participating  is 
pale  red. 

The  Tongue. — Leprous  lesions  of  the  tongue  may  appear  in  the 
form  of  tubercles  or  opaline  patches.  The  tubercles  exhibit  consider- 
able differences  in  size;  ordinarily  they  are  miliary,  lenticular,  pea- 
sized.  Sometimes  they  are  quite  voluminous,  hard  or  soft,  reddish 
or  livid  in  color,  and  with  a  smooth  or  vegetating  surface. 

The  most  characteristic  features  of  leprosj""  of  the  tongue  are 
nodules  seated  usually  in  the  middle  of  the  dorsum.  They  are  rarely 
found  elsewhere  than  on  the  dorsal  aspect.  The}'  are  usually  multi- 
ple and  may  be  discrete  or  confluent.  When  they  are  discrete  the 
tongue  has  an  irregular  lobulated  surface,  the  nodules  being  separated 
by  furrows.  When  confluent,  the  nodules  have  a  tessellated  forma- 
tion. The  fusion  of  the  tubercles  may  form  a  mammillated  plaque, 
with  a  grayish  surface,  as  if  cauterized  with  nitrate  of  silver.  Unlike 
intranasal  nodules  they  do  not  usualh^  break  down,  and  have  been 
known  to  persist  for  years  without  change. 

The  number  of  nodules  and  degree  of  infiltration  tend  to  increase 
until  the  tongue  becomes  enlarged,  thickened,  and  clums^',  sometimes 
twice  the  normal  size,  and  can  be  moved  with  difficulty,  mastication 
becomes  difficult  and  painful,  while  the  furrows  between  the  tubercles 
crack  and  fissure.  When  ulceration  occurs  the  ulcers  are  superficial 
with  slightl}^  undermined  edges  and  resemble  ulcerated  mucous 
patches;  the  resulting  scars  also  resemble  syphilitic  plaques.  The 
thickened  grayish  epithelium  may  come  awaj'^  in  rags,  leaving  the 
subjacent  parts  a  little  red  or  pale.  The  lingual  papillae  are  promi- 
nent, and  the  follicles  at  the  back  of  the  tongue  hypertrophied;  the 
two  branches  of  the  lingual  V  may  form  a  considerable  elevation. 

Sensibility^  is  usually  abolished  more  or  less  completely  in  the 
surfaces  occupied  by  the  leprous  infiltrations.  Deep  cauterizations 
with  a  hot  iron  may  occasion  no  sensation.  The  thermic  sensibilitj^ 
may  also  be  lost.  The  sense  of  taste  is  in  the  majority  of  cases  pre- 
served in  more  or  less  complete  integrity.  Only  occasionally  do  we 
see  pinhead  to  lentil-sized  nodules. 


LEPEOSY   OF  THE   MUCOUS  MEMBKANES.  493 

Lesions  of  the  moutli  may  be  accompanied  by  salivation  from 
reflex  irritation  of  the  salivary  glands. 

Palate  and  Uvula. — These  tissues  are  often  affected  coincideutly 
with  the  cutaneous  eruption  which  follows  an  attack  of  fever.  The 
palate  is  generally  occupied  by  a  sharply  limited  infiltration,  slightly 
raised  and  covered  with  a  bluish  or  grayish  opaline  or  epithelial 
coating,  which  may  be  slightl}'  eroded.  At  a  later  period  the  entire 
palatine  arch  may  become  covered  with  an  eruption  of  grayish  and 
flattened  tubercles  of  the  form  and  volume  of  a  split  pea.  These 
nodules  may  spread  over  the  uvula  and  the  anterior  pillars  of  the 
palate  in  quite  a  symmetrical  manner.  The  infiltration  may  extend 
forward,  involving  the  membrane  covering  the  hard  palate,  and  extend 
to  the  retrodental  furrows  situated  behind  the  sujDerior  incisors, 
often  leading  to  shedding  of  the  teeth,  especially  the  incisors.  The 
uvula  is  usually  elongated,  thickened,  and  of  a  peculiar  grayish-blue 
color.  A  tubercle  may  form  at  the  tip  of  the  uvula,  giving  a  bulbous 
appearance,  or  one  may  form  at  its  junction  with  the  velum,  causing 
oedema  and  hypertrophy.  The  whole  picture  of  the  palate  and  uvula 
is  strikingly  like  moist,  vegetating  syphilides. 

Sooner  or  later  there  is  erosion  or  ulceration  which,  as  a  rule, 
rapidly  cicatrizes.  The  anterior  surface  of  the  uvula  is  particularly 
prone  to  ulceration .  The  ulcers  are  usually  as  large  as  a  lentil,  and 
as  they  heal  new  ones  may  appear  until  the  whole  infiltration  may  be 
replaced  by  cicatricial  tissue.  As  the  ulcerated  uvula  heals  it  may  be 
contracted  towards  the  palate ;  or  it  may  be  fixed  in  one  of  various 
vicious  positions  from  adhesions  with  the  surrounding  structures. 
The  various  resulting  deformities  may  seriously  interfere  with  nor- 
mal deglutition — regurgitation  of  liquids  through  the  nose  is  com- 
mon. As  cicatrization  proceeds  there  is  more  and  more  shrinkage 
and  the  pressure  appears  to  cause  rarefaction  and  absorption  of  the 
palate  bones.  The  results  again  strikingly  resemble  the  destructive 
lesions  of  tertiary  syphilis,  although  the  pathogeny  is  quite  dif- 
ferent. 

It  is  to  be  observed  that  exceptionally  the  mucous  membrane  of 
the  palatine  arch  presents  a  remarkable  pallor,  and  that  this  ansemic 
condition  may  be  manifest  over  the  entire  extent  of  the  buccal  and 
pharyngeal  mucous  surfaces. 

Fauces. — Both  the  palatine  arches  and  the  tonsils  are  commonly 
affected.  The  ulceration  of  the  infiltrated  faucial  pillars  is  rather  su- 
perficial, while  that  of  the  tonsils  is  deeper  and  leads  almost  to  the 
effacement  of  these  structures.  The  leprous  ulcerations  of  the  ton- 
sil are  often  covered  with  a  grayish  diphtheroid  coating  and  simulate 
closely  syphilitic  ulcers  of  these  structures. 


494  MORROW — LEPROSY. 

F]iarij)ix. — The  posterior  wall  of  the  pharynx  often  escapes,  yet 
lua}'  be  involved  when  structures  like  the  nose  and  mouth  escape. 
Leprous  pharyngitis  resembles  leprous  rhinitis ;  the  membrane  is  oily, 
red,  and  shiny  as  if  varnished.  The  nasal  insufficiency  which  compels 
the  patients  to  breathe  almost  exclusively  through  the  mouth  is  prob- 
ably the  principal  cause  of  this  dry  and  parched  condition  of  the  mu- 
cous surfaces.  There  is  an  irregular  deposit  of  small  nodules  which 
become  eroded  or  ulcerated  and  heal  with  white  superficial  scars.  Ou 
account  of  coincident  anaesthesia,  patients  do  not  feel  much  pain  un- 
less there  are  deep  rhagades  or  deep  ulcers. 

Tlie  Ear. — Leloir  and  others  make  mention  of  certain  auditory 
troubles  which  occur  in  the  course  of  leprosy.  They  are  usually  con- 
fined to  noises  and  rumblings  in  the  ears  with  decided  dulness  in  the 
acuity  of  the  sense  of  hearing.  The  condition  of  the  alterations  in  the 
tonsil,  with  congestion  and  thickening  of  the  membrane  of  the  Eusta- 
chian tube  with  consequent  obstruction,  explain  these  auditor}^  phe- 
nomena. There  is  often  also  some  redness  and  congestion  of  the 
membrana  tympani.  The  hearing  may  also  be  temporarily  affected 
by  the  development  of  nodules  in  the  external  auditory  canal,  coinci- 
dent with  their  appearance  in  the  external  parts  of  the  ear. 

The  Larynx. — The  epiglottis  is  the  region  of  the  larj^nx  most  fre- 
quently involved  in  leprosy.  There  is  infiltration  or  hypertrophj'  of 
the  submucous  connective  tissue  and  the  epiglottis  becomes  thick- 
ened, tumefied,  and  stiff.  The  mucosa  maj''  remain  smooth  or  be 
studded  wdth  small  grayish  nodules,  and  the  iisual  ulceration  and 
scarring  may  be  present.  Sometimes  this  covering  becomes  thick- 
ened and  is  transformed  into  a  hard  spheroidal  mass,  which  is  main- 
tained above  the  vestibule  of  the  larynx  by  the  infiltrated  and  inex- 
tensible  aryteno-epiglottidean  folds,  and  the  functions  of  the  larynx 
are  gravely  compromised  (Jeanselme).  The  epiglottis  may  be  mark- 
edly' involved  and  the  rest  of  the  larynx  escape.  Similar  changes  may 
occur  in  the  arytenoid  cartilages.  A  peculiarity  of  this  locality  is 
thatfbut  one  side  may  be  involved. 

Next  in  frequency  to  the  preceding,  the  glossoepiglottic  and  ary- 
epiglottic  folds  are  involved  and  in  a  similar  manner.  The  true  cords 
frequently  exhibit  swelling  aud  thickening  which  maj-  in  time  lead 
to  ulceration,  and  later  may  involve  an  entire  cord.  The  tendency  of 
the  ulcers  to  cicatrize  is  very  marked,  and  not  only  the  true  but  the 
false  cords  may  be  destroyed.  As  a  result  of  the  ulcerative  process 
the  structures  of  the  larynx  are  often  changed  into  a  shapeless  mass  at 
an  advanced  i^eriod  of  the  disease.  These  changes  induce  hoarseness 
up  to  complete  aphonia  and  at  times  dyspnoea. 

Attacks  of  dyspnoea  from  laryngeal  stenosis  are  not  uncommon. 


LEPEOSY  OF  THE  MUCOUS  MEMBRANES.  495 

Tliey  may  result  suddenly  from  an  acute  oedema  conjoined  with  an 
acute  laryngitis  from  exposure  to  cold,  attended  with  suffocative 
symptoms  and  cyanosis,  or  they  may  develop  more  gradually  from 
the  thickened,  vegetating,  and  pachydermatous  condition  of  the  mu- 
cous covering  of  the  larynx. 

Alterations  of  the  voice  are  quite  common  during  all  the  stages  of 
leprosy.  The  significance  of  this  change  was  known  at  the  time  of 
Moses;  the  j^riest  recognized  the  leprous  by  commanding  them  to 
speak  before  him.  The  voice  ma}-  be  harsh,  raucous,  nasal,  or  other- 
wise altered  in  its  timbre.  In  other  cases  the  voice  becomes  thin, 
feeble,  or  there  may  be  aphonia  more  or  less  complete. 

According  to  Jeanselme  the  functional  disorders  of  the  voice  may 
be  produced  hy  two  mechanisms.  Sometimes  they  result  from  clo- 
sure of  the  glottic  opening  by  some  material  obstacle  (deposit  of 
tubercles  on  the  laryngeal  mucous  membrane,  destructive  lesions  of 
the  vocal  cords,  interarytenoid  pachydermia) ;  at  other  times  they  are 
the  consequence  of  an  insufficiency  of  the  glottis,  the  vocal  cords 
leaving  between  them  an  aperture  during  the  emission  of  sound.  This 
paralysis  of  the  vocal  cords  appears  to  be  determined  by  a  neuritis 
of  the  recurrent  laryngeal  nerve.  Lesions  of  the  cartilaginous  portion 
of  the  larynx  occur  ac  a  later  period  of  the  disease,  resulting  at  times 
in  necrosis  of  the  cartilage.  The  laryngeal  stenosis  is  often  so  pro- 
nounced that  tracheotomy  is  necessarj^  to  prolong  the  life  of  the  suf- 
ferer. All  observers  note  the  analogy  between  leprosy  and  tuberculo- 
sis of  the  larynx. 

Leprous  Affections  of  the  Eye. — The  frequency  with  which  the  eye 
is  affected  in  tubercular  leprosy  is  variously  estimated  at  from  sixty- 
six  to  seventy-five  per  cent.  Even  a  larger  proportion  is  given  by 
some  authorities.  As  the  leprous  process  almost  always  begins  in 
the  oculopalpebral  mucous  membrane,  these  affections  may  properly 
be  considered  under  this  head.  At  an  early  stage  of  the  disease, 
according  to  Daniellsen  and  Boeck,  the  white  of  the  eye  assumes  a 
muddy  appearance  and  the  vessels  of  the  cornea  are  seen  to  be  period- 
ically injected.  This  change  of  color  gradually  increases  and  usually 
produces  upon  the  sclerotic  towards  the  exterior  border  of  the  cornea  a 
grayish-yellow  thickening,  which  forms  around  the  cornea  a  rampart 
of  more  or  less  elevation.  The  thickening  progresses  simultaneously 
with  an  increase  of  vascular  congestion  until  the  whole  conjunctiva 
becomes  the  seat  of  the  specific  infiltration.  There  is  an  erj^the- 
matous  swelling  of  the  eyelids,  the  eyelashes  fall,  and  permanent  in- 
duration may  remain  along  the  tarsal  cartilages,  or  the  eyelids  may 
be  completely  invaded  by  leprous  tubercles.  The  disease  eventually 
extends  from  the  sclerotic  to  the  cornea.     The  original  infiltration, 


496  MORROW — LEPROSY. 

which  may  now  be  called  a  tubercle  on  account  of  its  increased  vol- 
ume, acquires  c-  brownish  color,  is  firm  to  the  touch,  and  extends 
through  the  thickness  of  the  cornea.  After  having  penetrated  through 
the  cornea  the  tubercle  reaches  the  iris,  which  then  assumes  a  dirty 
gra3dsh  color,  the  growth  eventually  passing  into  its  substance. 
The  pupil  becomes  irregular  and  the  anterior  chamber  is  gradually 
filled  Avith  tubercular  matter.  The  j^atient  feels  lancinating  pains  in 
the  eye  and  the  sight  is  extinguished.  The  disease  progresses  up  to 
the  complete  occupation  of  this  chamber  and  the  invasion  of  the 
entire  cornea  by  the  yellowish-white  matter.  The  eye  is  then  a 
shapeless  mass.  There  is  produced  a  sort  of  staphylomatous  tumor 
which  increases  to  such  an  extent  that  the  eyelids  no  longer  cover  it. 
After  a  time  the  tubercular  mass  softens,  the  tumor  contracts,  and  the 
eye  can  again  be  closed. 

Instead  of  this  mode  of  invasion  the  iris  maj-  be,  according  to 
Leloir,  independently  and  primaril}-  involved,  constituting  a  leprous 
iritis  and  resembling  certain  forms  of  syphilitic  gummous  iritis. 
The  tubercle  penetrates  into  the  posterior  chamber,  producing  poste- 
rior synechiae,  and  extends  over  the  anterior  surface  of  the  crystalline 
lens.  It  sends  prolongations  into  the  anterior  chamber,  which  may 
unite  with  prolongations  of  the  tubercles  which  have  invaded  the  cor- 
nea. The  almost  invariable  termination  of  this  leprous  iritis  is  loss 
of  sight.  At  other  times  there  may  be  a  diffuse  lesion  of  the  iris, 
iridocyclitis.  According  to  Hansen,  thirtj'  per  cent,  of  tubercular 
lepers  have  lesions  of  the  iris. 

These  ophthalmic  lesions  may  be  acute  or  subacute  in  their  evolu- 
tion, but  the  almost  invariable  termination  is  partial  or  comjjlete  loss 
of  vision.  According  to  Hardy,  the  ulcerated  surfaces  of  the  eye- 
lids may  contract  adhesions  with  those  of  the  sclerotic,  and  the  eye 
is  then  immobilized  in  its  socket. 

The  (jeiutal  mucous  membranes  may  also  be  the  seat  of  leprous 
lesions.  The  balanopreputial,  or  the  vulvar,  and  the  anal  mucous 
membranes  are  sometimes  involved  and  then  become  the  seat  of  tu- 
bercles. 

Period  of  Ulceration. 

We  have  seen  that,  in  their  ordinary  evolution,  the  lejn'ous  tuber- 
cles come  out  in  successive  crops,  usually  preceded  by  febrile  at- 
tacks ;  that  the  earlier  tubercles  are  usually  resorbed  or  ulcerate  and 
may  entirely  disappear ;  and  that  the  disappearance  of  one  group  is 
succeeded  by  another  in  the  same  or  new  regions  at  variable  inter- 
vals. After  they  have  attained  a  certain  degree  of  development  the 
tubercles  may  remain  for  weeks,  months,  or  years  without  retrogress- 


ULCERATIVE  STAGE  OF  TUBERCULAR  LEPROSY.  497 

ive  changes,  but,  eventually,  as  in  the  case  of  other  new  formations 
of  the  granuloma  type,  the  leprous  tubercle  shows  a  tendency  to 
disappear  by  resorption  or  fibroid  degeneration,  or  by  softening, 
breaking  down,  and  discharge  of  its  contents.  The  one  process  is 
essentially  curative  and  healing,  the  other  destructive. 

The  stage  of  ulceration  marks  a  period  in  the  life  term  of  the 
neoplasm.  Undoubtedly  many  tubercles  ulcerate  as  a  result  of  ex- 
ternal injury,  but  in  most  cases  the  ulcerative  process  occurs  as  a 
natural  phase  of  the  evolution  of  the  disease.  It  is  held  by  some  that 
the  non-^dability  or  inaptitude  for  permanent  organization  of  the 
tubercles  is  caused  by  the  gradual  accumulation  of  the  bacilli  in 
the  perivascular  spaces  and  the  obliteration  of  the  vessels,  when  the 
neoplasms,  being  deprived  of  their  blood  supply,  undergo  necro- 
biotic  changes.  Central  mortification  is  first  noted  in  the  skin,  which 
softens  in  the  centi-e,  breaks,  and  gives  exit  to  the  contents  of  the 
tubercles. 

The  capability  of  the  lepra  bacillus  to  induce  suppuration  by  its 
presence  is  undetermined,  and  it  is  a  question  what  is  the  role,  if 
any,  the  pyogenic  microbes  play  in  the  jjroduction  of  the  suppurative 
process.  Impey  thinks  that  suppuration  of  the  inguinal  glands  and 
other  ganglia  occurs  through  the  action  of  pyogenic  cocci  and  not 
through  that  of  lepra  bacilli.  In  one  form  of  ulcerative  lesion,  mal 
perforans,  the  lepra  bacilli  are  absent. 

Fibroid  Degeneration. — In  many  cases  the  neoplasms  undergo  a 
sort  of  fibroid  degeneration.  As  a  result  of  frequently  recurring  con- 
gestive processes  there  is  a  formation  of  connective  tissue,  and  a 
fibrous  metamorphosis  is  effected  in  much  the  same  manner  as  in  cer- 
tain tuberculides  {lupus  sclereux).  The  repeated  congestive  attacks 
result  in  the  formation  of  cicatricial  tissue,  which  limits  the  multipli- 
cation of  the  bacilli  and  is  essentially  a  conservative  element  in  the 
disease.  This  fibroid  degeneration  is  marked  by  a  diminution  in  the 
volume  of  the  tubercle ;  it  becomes  smaller,  firmer,  and  more  indu- 
rated. On  section  of  the  tubercle  it  is  seen  to  be  composed  almost 
entirely  of  fibrous  tissue,  which  renders  it  inapt  for  the  germination 
of  the  bacilli.  These  sclerosed  tubercles  are  frequently  permanent 
and  may  become  keloidal.  When  this  fibrous  transformation  occurs 
in  all  the  tubercles,  the  disease  is  said  to  be  arrested. 

The  same  fibrous  transformation  may  occur  in  the  diffuse  infil- 
trations (lepromes  en  nappe).  The  surface  becomes  browner,  with 
increased  desquamation.  Gradually  the  infiltration  in  its  entire  ex- 
tent becomes  resorbed,  leaving  a  superficial  pigmented  cicatrix.  It 
has  been  observed  that  this  change  may  take  place  coincidently  with, 
or  as  a  result  of,  an  attack  of  erysipelas. 
Vol.  XVIII.— 32 


498  MORROW— LEPROSY. 

Interstitial  Resorption. — In  some  cases  the  tubercles  haviDg  at- 
taiued  a  certain  degree  of  development,  a  retrogressive  process  takes 
place  without  open  ulceration ;  the  tumors  disappear  by  a  process  of 
interstitial  resorption.  The  upper  portion  of  the  nodule  becomes 
less  prominent,  often  sinking  in  the  centre,  giving  it  an  umbilicated 
appearance ;  and  there  is  a  progressive  diminution  of  this  central  por- 
tion of  the  nodule  until  only  a  narrow  circular  wall  of  infiltration  is 
left,  which  finally  disappears,  leaving  a  grayish  or  brownish  pigment- 
ed cicatrix. 

Ulceration. — The  ulcerative  process  varies  accordingly  as  the  necro- 
biosis involves  the  centre  or  the  totality  of  the  tubercle.  In  the  for- 
mer case  the  skin  over  the  centre  of  the  tubercle  becomes  softened,  and 
one  or  more  yellowish  points  are  seen  which  soon  open  and  discharge  a 
thick  viscid  or  purulent  yellow  matter,  which  concretes  in  greenish, 
brownish,  or  blackish  crusts,  resembling  the  crusts  of  s^-philitic  ulcers. 
The  ulcer  is  round,  irregular,  the  edges  are  often  perpendicular  or  un- 
dermined, the  base  is  reddish-brown,  grayish,  or  pseudomembranous, 
sometimes  fungous,  secreting  a  sanious  pus.  These  ulcers  are  indo- 
lent and  may  persist  for  mouths  or  years  practically  unchanged. 

In  other  cases  in  which  the  totalitj^  of  the  tubercle  is  involved  in  the 
suppurative  process  the  entire  neoplasm  disappears  by  purulent  dis- 
solution, and  the  contents  are  discharged  en  masse,  as  in  an  abscess. 
The  cavity  may  remain  open  for  a  long  time,  with  a  resistant  infiltrated 
wall,  and  the  crateriform  ulcer  thus  left  as  a  rule  cicatrizes,  leaving  a 
slightly  depressed,  wrinkled  cicatrix.  Not  infrequently  two  or  more 
ulcers  may  unite  to  form  a  large  irregular  ulcer ;  or  the  whole  body 
may  be  the  seat  of  these  disfiguring  ulcers  and  crusts.  Leprous  ulcers 
seem  to  heal  with  remarkable  facility  under  the  influence  of  rest  and 
aseptic  dressings,  and  the  extensive  cavities  are  filled  with  cicatricial 
tissue.  The  resulting  cicatrices  are  hard,  irregular,  often  white  iu 
the  centre,  and  surrounded  by  a  brownish  ring  of  pigmentation. 

This  cicatricial  tissue  may  afterwards  become  the  seat  of  tubercles. 
It  is  to  be  noted  that  the  development  of  new  tubercles  is  often  syn- 
chronous with  the  ulceration  and  disappearance  of  old  ones.  While 
certain  tubercles  are  being  eliminated  by  ulceration  and  subsequent 
cicatrization,  new  tubercles  appear  which  soften  and  ulcerate  in  their 
turn. 

The  course  and  character  of  the  leprous  ulceration  are  modified  ac- 
cording to  its  situation  and  also  by  the  intercurrent  processes  of  ery- 
sipelas-like inflammations  and  gangrene.  Tubercles  on  the  extrem- 
ities are  more  apt  to  break  down  into  ulcerative  lesions,  as,  for  example, 
upon  the  dorsal  surfaces  of  the  feet  and  ankles,  the  legs,  backs  of  the 
hands  and  forearms,  and  the  face.     When  an  ulceration  is  about  to 


TERMINATION   OF   TUBEECULAR  LEPROSY.  499 

occur  in  these  localities,  tlie  skin  becomes  swollen,  and  in  tliis  infil- 
trated skin  violaceous,  livid  spots  form,  which  open  in  a  few  days  and 
discharge  an  acrid,  viscid  material. 

The  occurrence  of  ulceration  on  the  lower  extremities  is  deter- 
mined partly  by  dystrophic  conditions  here  present  in  the  shape  of 
marked  oedematous  infiltration — a  hard,  brawny,  pachydermatous 
condition  of  the  integument  which  is  sometimes  so  pronounced  as  to 
suggest  elephantiasis  arabum.  The  contusions,  injuries,  and  various 
traumatisms  to  which  lesions  in  these  localities  are  subjected,  as  well 
as  lack  of  cleanliness,  doubtless  act  as  exciting  causes.  The  ulcera- 
tion rapidly  extends  and  may  involve  the  intervening  tissues  and  sur- 
rounding surfaces  over  a  considerable  area.  It  may  advance  around 
the  limb,  like  varicose  or  sj^philitic  ulcers  of  the  lower  extremities, 
or  cover  the  entire  dorsal  surface  of  the  feet  and  ankles.  The  ulcera- 
tions are  sometimes  quite  extensive  both  in  area  and  depth.  They 
may  take  on  a  gangrenous  action  and  cause  profound  loss  of  tissue, 
sometimes  ploughing  up  the  soft  tissues  and  laying  bare  the  ligaments 
and  bones,  with  necrosis  consecutive  to  the  osseous  denudations. 

The  destructive  changes  which  occur  at  this  stage  of  the  disease 
in  the  nasal  fosste,  palate,  larynx,  and  trachea  have  been  considered 
in  connection  with  leprosy  of  the  mucous  membranes. 

It  has  been  observed  that  intercurrent  acute  diseases  may  produce 
a  temporary  subsidence  of  the  tubercles.  After  an  attack  of  erysipe- 
las, smallpox,  or  other  acute  infectious  disease  many  tubercles  often 
disappear.  The  beneficial  effect  of  these  intercurrent  inflammations 
has  been  explained  on  the  ground  that  they  alter  the  blood  supply  to 
the  part,  while  at  the  same  time  they  favor  absorption.  Eeference 
will  be  again  made  to  these  points  in  connection  with  the  complica- 
tions of  leprosy. 

Termination. 

As  leprosy  advances  in  its  evolution,  all  the  symptoms  increase  in 
intensity  and  severity.  In  connection  with  the  ulcerative  processes, 
evidences  of  profound  cachexia  are  usually  manifest,  due  to  leprous 
deposits  in  the  viscera  or  amyloid  degeneration  of  internal  organs. 
Unless  the  unfortunate  patient  is  carried  off  by  some  intercurrent 
disease,  he  may  live  for  years  suffering  a  slow  and  progressive  de- 
composition of  the  hodj  through  the  breaking  down  and  ulceration 
of  the  organs  invaded  by  the  leprous  deposits. 

The  chief  causes  of  death  are  usually  tuberculosis,  enteric  compli- 
cations with  colliquative  diarrhoea,  exhaustion  from  ulceration  and 
gangrene,  renal  disorders  resulting  in  dropsy,  pulmonary  lesions, 
suffocation  from  oedema  of  the  glottis,  or  stenosis  of  the  larynx  or  tra- 


500  MORROW— LEPROSY. 

chea.  The  visceral  complications  liave  been  generally  regarded  as 
tuberculous  in  character,  but  it  has  been  suggested  by  Arning  that  we 
have  been  mistaken  in  attributing  deaths  of  lepers  to  intercurrent 
pneumonias,  phthisis,  and  dysentery,  which  were  simulated  by  the 
clinical  symptoms. 

Although  leprosy  is  regarded  as  among  the  most  fatal  of  all  dis- 
eases, however  paradoxical  the  statement  may  seem,  the  leper  seldom 
dies  of  leprosy. 

According  to  the  tables  of  Hillis,  thirty-eight  per  cent,  of  lepers 
die  of  internal  leprous  deposits,  marasmus,  atrophy,  suffocation  from 
cedema  of  the  glottis  or  laryngeal  stenosis,  or  exhaustion  from  leprous 
ulceration,  Avhich  may  be  the  immediate  consequences  of  the  disease 
itself.  This  proportion  of  deaths  due  directly  to  leprosj'  is  i:)robably 
too  high.  Lepers  commonly  die  of  terminal  infections  which  have 
no  necessary  connection  with  the  disease,  as  albuminous  nephritis, 
phthisis,  bronchitis,  pneumonia,  diarrhoea,  etc. 

That  tubercular  leprosy  progresses  to  a  fatal  termination  is  a  rule 
to  which  there  are  few  exceptions.  There  have  been  cases,  exceed- 
ingly rare,  in  which  the  tubercles  have  entirely  disappeared,  the 
ulcerations  have  healed,  and  there  has  been  a  definite  cessation  of  all 
further  manifestations.  The  fires  of  the  disease  have  apparently 
burned  out,  and  the  patient  lives  for  years,  showing  in  his  scarred 
and  disfigured  features  the  traces  of  the  destructive  process  which  has 
swept  over  them,  and  finally  dies  of  some  independent  disease. 

Daniellsen  reports  three  cases  of  permanent  arrest  of  the  disease, 
in  one  of  which  there  had  been  complete  exemption  from  all  leprous 
manifestations  for  thirty  years.  In  another  case,  that  of  a  woman, 
the  cure  had  been  complete  for  twenty  years.  Kaurin  reports  a  case 
in  which  there  was  a  complete  disappearance  of  the  tubercles  with 
apparent  cure  which  persisted  for  many  years,  the  patient  finally 
dying  of  cerebral  hemorrhage  at  the  age  of  ninety-five.  The  autopsy 
showed  no  evidence  of  the  bacilli  in  the  integument  or  internal  organs. 
In  another  case  there  was  a  complete  disappearance  of  all  accidents 
for  twelve  years  or  more,  the  patient  remaining  in  good  health. 
Cases  of  real  and  api)areufc  cure  have  been  reported  by  others. 

It  is  well,  however,  to  distrust  the  authenticity  of  many  cases 
of  reported  cures,  unless  a  considerable  lapse  of  time  has  ensued  after 
the  disappearance  of  all  accidents.  The  disease  may  reawaken  into 
activity  after  a  long  period  of  exemption  from  all  manifestations  and 
new  tubercles  form,  or,  as  it  sometimes  happens,  after  the  ulcers 
lipve  entirely  healed  there  may  be  what  is  termed  a  visceral  metas- 
tasis, a  determination  of  the  morbid  process  to  the  lungs,  liver,  kid- 
neys, or  some  other  important  organ,  which  soon  leads  to  a  fatal  ter- 


COMPLICATIONS  OF  TUBERCUIAE  LEPROSY.  501 

mination.  Tlie  most  hopeful  prognosis  justified  by  observation  of 
the  usual  course  of  the  disease  is  that  the  tubercular  leper  may  be- 
come an  anaesthetic  leper. 

Cases  of  metamorphosis  of  the  tubercular  into  the  anaesthetic  form 
are  by  no  means  rare.  The  pathological  explanation  of  this  transfor- 
mation would  seem  to  be  simplj^  a  migration  of  the  bacilli  from  the 
integument  into  the  previously  immune  nerve  tissues.  In  many  cases 
of  advanced  tubercular  leprosy,  this  transition  is  shown  by  the  super- 
vention of  anaesthesia,  atrojphy,  and  other  symj)toms  peculiar  to  anaes- 
thetic leprosy. 

In  one  class  of  cases  there  seems  to  be  a  merging  or  rather  a  pass- 
age of  the  one  form  into  the  other  by  almost  insensible  gradations. 
Coincidently  with  the  disappearance  of  the  tubercles  and  the  healing 
of  the  ulcers  there  is  the  appearance  of  the  characteristic.symptoms  of 
the  anaesthetic  form:  atrophies,  paralyses,  enlargements  of  the  nerves 
and  consecutive  trophic  troubles  in  the  shape  of  deformities  and  mu- 
tilations. Leloir  has  sometimes  observed  that  in  old  tubercular 
leprosy  which  had  become  associated  with  nerve  leprosy,  the  skin, 
subcutaneous  tissue,  and  muscles  of  the  face  acquire  a  gelatinous 
appearance  and  trembling  due  to  a  kind  of  colloid  degeneration. 

In  other  cases,  instead  of  this  gradual  transition  of  one  form  into 
another,  the  tubercles  disappear  completely  and  the  patient  seems 
cured  of  his  leprosy.  After  a  period  of  exemption  from  all  accidents 
there  may  be  a  macular  eruption,  followed  b}^  the  regular  evolution 
of  symptoms  of  anaesthetic  leprosy,  precisely  as  if  there  had  been  a 
fresh  infection.  Daniellsen  has  observed  a  case  of  this  kind  in  which, 
six  years  later,  the  anaesthetic  form  was  still  maintained  with  all  its 
characteristic  features. 

Complications  and  Conditions  Influencing  the    Course    of 

Leprosy. 

Leprosy  may  be  complicated  with  various  parasitic  and  other 
affections  of  the  skin,  as  scabies,  favus,  ringworm,  eczema,  psoriasis, 
etc.  The  incidence  of  these  affections  is  much  larger  in  tropical 
countries,  where  a  greater  surface  of  the  body  is  habitually  exposed 
and  where  parasitic  affections  of  the  skin  are  more  common  and  of 
more  luxuriant  development.  It  is  sometimes  difficult  to  discriminate 
between  the  incipient  manifestations  of  leprosy  and  chromophytosis 
and  other  parasitic  affections. 

Daniellsen  and  Boeck  say  that  in  Norway  leprosy  is  almost  con- 
stantly complicated  with  some  chronic  cutaneous  malachj,  the  most 
common  being  Norwegian  scabies.     Besides  introducing  an  element 


502  MORROW — LEPROSY. 

of  confiisiou  iu  diagnosis,  the  breaks  aud  excoriations  of  the  skin 
which  commonly  attend  these  parasitic  dermatoses  are  considered  to 
afford  favorable  spots  for  the  entrance  of  the  leprous  virus  and  thus 
constitute  an  important  agency  in  the  propagation  of  the  disease. 
Under  the  improved  hygiene  which  has  taken  place  in  recent  years  this 
complication  is  not  at  the  present  time  nearly  so  frequent  as  formerly. 

The  foramina  contagiosa  effected  iu  prurigo,  eczema,  and  other 
])arasitic  dermatoses,  by  scratching  or  wounding  the  integument,  are 
regarded  by  Hebra  and  others  as  channels  of  entrance  of  the  bacilli 
into  the  system. 

The  complication  with  yaws  or  framboesia  and  also  with  elephan- 
tiasis arahum,  has  been  noted  in  countries  where  these  diseases  exist. 
It  is  a  matter  of  some  scientific  interest  perhaps  that  elephantiasis 
arabum  is  very  common  in  the  Samoan  Islands,  where  leprosy  is,  or 
was  a  few  years  ago,  unknown,  while  the  former  disease  is  not  met 
with  in  the  Sandwich  Islands,  where  leprosy  is  so  i)revalent. 

Leloir  was  impressed  with  the  remarkable  coincidence  of  goitre 
and  leprosy  in  Italy.  Among  twelve  Italian  whom  he  observed  in  the 
north  of  the  peninsula,  six  were  affected  with  goitre. 

Si/philis  often  complicates  leprosy.  In  a  number  of  cases  which 
have  come  under  my  observation  in  the  Charity  Hospital  of  New 
York  syphilis  was  also  present.  Each  disease,  however,  seems  to 
run  an  independent  course,  although  it  has  been  said  that  the  tertiary 
accidents  of  syphilis  are  rarely  seen  in  sj'philitic  lepers.  The  ante- 
cedents of  lepers  are  often  syphilitic,  and  this  is  regarded  by  many 
as  constituting  one  of  the  most  important  predisposing  causes  of 
leprosy.  The  native  population  of  the  Sandwich  Islands  was  at  one 
time  almost  decimated  by  syphilis,  and  the  impaired  constitutions 
resulting  from  these  syphilitic  progenitors,  coupled  with  the  feeble 
capacity  of  resistance  of  the  native  Hawaiians,  has  always  been  re- 
garded as  among  the  chief  causes  of  their  remarkable  susceptibility 
to  leprosy  and  its  rapid  spread  among  them. 

The  similarity  of  the  two  diseases  in  certain  objective  characters 
and  their  frequent  coincidence  led  to  the  erroneous  opinion  that  lep- 
rosy was  a  modified  syphilis  or,  as  it  has  been  termed,  "a  fourth 
stage  of  syphilis."  The  broad  lines  of  distinction  between  these  two 
diseases  are,  however,  too  obvious  to  merit  special  mention. 

Impey  describes  under  the  title  of  "Syphilitic  Leprosy"  a  form 
of  the  disease  which  he  regards  as  worthy  of  sei)arate  designation. 
"  Though  produced  by  the  combination  of  two  distinct  diseases,  yet 
each  malady  modifies  the  other  in  such  a  marked  manner  that  the 
distinctive  characters  of  the  primary  disease  are  lost  in  the  combined 
diseases."     He  says  that  in  these  cases  of  syphilitic  leprosy  "the 


CONDITIONS   INFLUENCIN'G  THE   COURSE   OF  TUBERCULAR   LEPROSY.    503 

mouth  and  tliroat  become  much  affected,  the  hair  is  removed  from 
the  scalp  in  large  patches,  bones  in  various  parts  of  the  body  become 
necrosed,  lymphatic  glands  are  enlarged  and  often  suppurate.  Indo- 
lent abscesses  are  formed  in  various  regions,  the  bones  of  the  nose 
are  soon  lost,  and  the  nose  itseK  is  soon  removed  by  ulceration ;  these 
symptoms  being  almost  entirely  due  to  the  syphilitic  poison.  When 
to  these  disfigurements  the  deformities  of  leprosy  are  superadded, 
the  symptoms  produced  are  almost  too  terrible  to  behold,"  etc. 

Tuberculosis  may  also  complicate  leijrosy,  in  some  cases  consti- 
tuting the  primary  affection  upon  which  leprosy  has  been  engrafted. 
More  commonly,  however,  tuberculosis  represents  a  terminal  infec- 
tion and  is  the  chief  cause  of  death  from  its  visceral  complications. 
In  his  investigations  of  leprosy  in  Norway,  Leloir  was  struck  by 
the  enormous  number  of  persons  affected  hj  scrofula,  tuberculosis, 
anaemia,  and  chlorosis  in  the  leprous  regions  he  visited.  The  coinci- 
dence of  the  scrofulous  diathesis  with  leprosy  determines  a  marked 
modification  in  the  character  and  course  of  the  leprous  manifesta- 
tions. Many  observers  agree  that  scrofula  exercises  a  certain  influ- 
ence on  the  leprous  tubercles  which  take  on  a  "  scorbutic  appearance.'' 
Leprosy  occurs  very  often  in  persons  of  scrofulous  and  tuberculous 
antecedents.  Verteuil,  quoted  by  Leloir,  has  often  noted  the  coinci- 
dent occurrence  of  pulmonary  phthisis  and  leprosy  in  families.  In  a 
European  family  of  eight  children,  two  of  the  boys  died  of  leprosy, 
and  the  third  boy  and  two  sisters  succumbed  to  pulmonary  phthisis. 

Tlie  eruptive  fevers  exert  a  marked  influence  upon  the  course  of  the 
leprous  process.  An  attack  of  typhoid  fever,  pneumonia,  etc.,  may 
cause  the  rapid  involution  of  the  lei)rous  lesions,  which  may  not  re- 
appear for  a  long  time.  Hardy  speaks  of  the  good  effects  of  an  inter- 
current attack  of  smallpox.  Vaccination  is  sometimes  said  to  exert 
an  equally  favorable  influence.  Beavan  Rake  particularly  noted  first 
swelling  and  then  disappearance  of  the  tubercles  in  patients  whom 
he  had  vaccinated. 

In  the  case  of  the  acute  infectious  diseases,  there  seems  to  be  a 
sort  of  antagonism  between  the  newly  introduced  parasites  and  those 
of  leprosy.  The  former,  temporarily  at  least,  dominate  the  patho- 
logical field  and  prevent  the  development  and  multiplication  of  the 
lepra  bacilli. 

The  salutary  influence  of  an  attack  of  erysipelas  in  causing  the 
disappearance  of  leprous  manifestations  has  been  attested  by  many 
observers.  The  curative  action  of  erysipelas,  as  in  other  infectious 
diseases,  is  not  as  a  rale  durable,  but  causes  only  a  temporary  inter- 
ruption to  the  course  of  leprosy. 

An  acute  attack  of  pulmonary  phthisis  may  also  arrest  and  render 


504  MORROW — LEPROSY. 

stationary  the  course  of  leprosy.  Leloir  found  that  it  caused  tlie  dis- 
ajjpearance  of  the  cutaneous  tubercles.  In  this  class  of  cases  there  is 
8irai)ly  the  introduction  of  a  new  pathogenic  factor  which,  as  it  is 
more  acute  in  its  development,  takes  precedence  for  the  time  being.    • 

Malaria  would  seem  to  exercise  a  most  unfavorable  influence  upon 
leprosy.  It  has  been  noted  that  the  course  of  the  disease  is  more 
rapid  and  severe  in  persons  who  live  in  low,  damp  dwellings  exposed 
to  marshy  and  malarial  emanations.  It  has  also  been  observed  that 
the  removal  of  a  leper  to  a  non-malarial  region  is  almost  invariably 
followed  by  an  improvement  of  at  least  temporary  duration. 

Cold  and  CJuoige  of  Season. — Undoubtedly  the  course  of  leprosy 
is  influenced  by  the  change  of  seasons,  especially  in  latitudec  where 
temperature  changes  are  sudden  and  severe. 

Cold  seems  to  exercise  a  special  excitatory  influence  upon  the 
leprous  process.  The  relation  between  the  so-called  "  congestive 
attacks"  or  exacerbations  and  cold  has  been  remarked  b}'  numerous 
observers.  There  can  be  no  doubt  that  cold  in  some  way  or  another 
exacerbates  the  disease.  My  observation  of  a  number  of  leprous 
patients  goes  to  show  that  in  this  climate  they  are  better  in  summer 
than  in  winter.  With  the  approach  of  colder  weather  in  September 
and  October,  many  of  the  symi:)toms  which  had  entirely  disappeared 
or  were  in  abeyance  during  the  summer  begin  to  revive  and  become 
aggravated,  and  this  irrespective  of  the  type  of  the  disease. 

This  seasonal  exacerbation  of  leprous  symptoms  represents  another 
of  the  numerous  analogies  of  the  disease  with  tuberculosis.  The  rea- 
son why  patients  sufi"ering  from  pulmonary  tuberculosis  are  better  in 
warm  than  in  cold  weather  is  not  far  to  seek,  but  why  aggravation  of 
the  tuberculous  process,  irrespective  of  the  localization  of  the  tuber- 
cles, should  take  place  in  cold  weather  is  not  so  evident.  Hutchin- 
son's testimony  is  that  lupous  patients  get  better  in  summer  and  grow 
worse  in  winter. 

One  reason  why  the  more  virulent  tubercular  form  of  leprosy  pre- 
dominates in  cold  climates  may  be  due  to  the  fact  that  cold  more  than 
any  other  external  factor  favors  the  growth  and  multiplication  of  the 
bacilli. 

Anaesthetic  Leprosy. 

The  anesthetic  form  presents  a  characteristic  variety  and  com- 
plexity of  symptoms.  It  possesses  a  physiognomy  peculiarly  its 
own,  and  its  clinical  aspect  is  so  entirel\^  different  from  that  of  tuber- 
cular leprosy  that  it  is  difficult  to  recognize  it  as  a  form  of  the  same 
disease  due  tc  the  action  of  an  identical  pathogenic  factor.  The  phe- 
nomena arc  essentially  those  of  multiple  neuritis,  consisting  princi- 


SYMPTOMS   OF  ANiESTHETIC  LEPROSY,  505 

pally  of  disorders  of  sensation  and  nutrition.  The  trophic  troubles 
whicli  are  consecutive  to  the  lesions  of  the  peripheral  nerves  are  dis- 
tinctive of  this  form  of  leprosy. 

The  2^€riod  of  hicahation  is  usually  more  prolonged,  which  may 
be  due  to  the  small  number  of  bacilli  or  the  greater  resisting-power 
of  the  organism  to  their  inroads.  Its  onset  is  gradual  and  insidious, 
and  the  prodromes  are  distinguished  by  the  absence  of  febrile  symp- 
toms, as  a  rule,  and  the  more  pronounced  character  of  the  subjective 
symptoms  of  hyperaesthesia,  pruritus,  and  pain. 

CuTAKEOus  Manifestations. 

The  Erythematous  Eruption. — The  first  cutaneous  manifestation  of 
nerve  leprosy  is  usually  in  the  form  of  a  localized  erythema.  Excep- 
tionally the  initial  lesion  may  be  in  the  form  of  bullae.  In  two  of  my 
cases  the  formation  of  bullae  preceded  by  several  months  the  ap- 
pearance of  any  macular  lesion.  The  appearance  of  the  macular 
exanthem  is  so  constant  a  phenomenon  that  Hansen  proposed  substi- 
tuting the  title  "macular"  for  anaesthetic  leprosy;  yet  it  is  to  be 
observed  that  in  certain  cases  the  macules  may  be  entirely  absent  and 
the  inital  symptoms  consist  of  motor  and  sensory  paralj'ses. 

While  the  cutaneous  eruption  in  nerve  leprosy  is  perhaps  not  so 
essentially  a  part  of  the  morbid  process  as  in  tubercular  leprosy,  which 
is  localized  in  the  skin,  the  macules  exhibit  a  greater  varietj^  of  aspect, 
especially  in  their  configuration  and  coloring.  This  is  due  largely  to 
the  fact  that  instead  of  being  transitory  and  evanescent,  they  usually 
remain  permanently  and  show  a  tendency  to  increase  hj  peripheral 
extension  while  clearing  in  the  centre,  and  also  to  the  fact  that  more 
pronounced  pigment  changes  occur  during  their  evolution.  The  mac- 
ules may  be  simply  erythematous,  afterwards  becoming  pigmented  or 
achromatic,  or  they  may  be  pigmented  or  achromatic  from  the  first, 
without  preceding  hyperaemia  or  congestion. 

The  first  appearance  of  the  eruption  often  follows  exposure  to  cold 
or  damp.  Many  persons  date  its  origin  to  a  cold,  and  it  is  usually 
preceded  by  a  sense  of  formication,  tingling,  burning,  or  stinging. 
The  spots  may  develop  without  any  subjective  sensations,  the  i^atient 
discovering  them  by  accident.  In  persons  who  are  not  observant 
or  when  the  spots  ajjpear  upon  the  covered  portions  of  the  body,  they 
may  exist  for  a  long  time  without  the  knowledge  of  the  patient. 
In  the  patient,  whose  face  is  portrayed  in  Fig.  7,  there  was  upon 
the  dorsal  surface  of  the  foot  a  large  discrete  red  patch,  which  from 
its  size  and  other  objective  characteristics  must  have  existed  for  a 
long  time  and  which  the  patient  discovered  by  accident.     In  another 


506 


MORROW — LEPROSY. 


case  I  found  lar^e  patches  upon  tlie  buttocks,  of  the  existence  of  which 

the  patient  was  ignorant. 

The  efflorescence  may  resemble  polymorphous  erythema  upon  its 

first  appearance.     The  macules  are  usually  circular  or  oval  in  outline, 

or  they  may  be  irregu- 
lar in  shape  (Fig.  6). 
They  vary  in  size  from 
that  of  a  finger-nail  to 
that  of  a  silver  dollar 
or  larger.  They  are 
usually-  small  on  their 
first  appearance,  but 
slowly  increase  in  size. 
Their  contour  is  grad- 
uallj-  lost  in  the  color- 
ing of  the  surrounding 
skin,  so  it  is  impossi- 
ble definitely  to  define 
their  limits.  In  some 
cases  they  exhibit 
sharply  defined  dentate 
margins,  as  seen  in 
Figs.  6  and  7. 

The  color  of  the 
erythematous  spots 
varies  fi'om  a  delicate 
pink  or  red  to  a  yel- 
lowish or  bluish-red 
color,  which  later  may 
deepen  into  a  brown- 
ish-yellow, slaty,  or 
black  shade.  The 
gradations  depend 
largely  upon  the  race 
and  complexion  of  the 
individual     and     the 

chronicity  of  the  patch.     As  they  grow  older  they  exhibit  a  greater 

variety  of  tints. 

In  many  cases  the  redness  may  be  so  little  pronounced  that  the 

patieut  does  not  perceive  it;  it  disappears  on  pressure,  to  reappear 

immediately.     It  may  fade  out  temporarily,  leaving  a  grayish  or  ye\- 

lowish  tint.     Friction,  heat,  and  cold,  especially  cold,  accentuate  it. 

I  have  found  that  patches  may  be  well  defined  by  the  application  of 


Fig.  6. — Macular  Lesions  of  Anajsthetic  Lepros.v. 


SYMPTOMS   OF   ANESTHETIC   LEPKOSY.  507 

cold  water  to  tlie  surface.  In  the  earlier  stage  oue  may  observe  the 
dilatation  of  the  cutaneous  capillaries ;  later  these  spots  may  become 
brown  or  black,  constituting  one  of  the  forms  described  by  early 
writers  as  morphoea  nigra. 

The  achromatic  patches  may  result  from  the  involution  of  the 
pigmented  macules,  or  they  appear  at  first  as  perfectly  white  patches 
upon  the  healthy  skin  (morphcea  alba).  This  latter  form  is  rarely 
seen  in  the  white  race ;  it  is  more  common  in  dark  races  and  in  trop- 
ical countries.  I  have  seen  many  examples  in  the  Hawaiian  lepers. 
Sometimes  these  decolorized  jDatches  are  surrounded  by  a  hyperchro- 
matic  margin. 

The  surface  of  the  patches  in  the  earlier  stage  is  perfectly  smooth. 
After  their  complete  development  there  is  more  or  less  continue  as 
desquamation  from  the  surface  of  the  patches,  which  is  usually  of  a 
bran-like,  furfuraceous  character.  In  rare  cases,  when  there  is  great 
disturbance  of  the  circulator}^  equilibrium,  the  epidermis  may  peel 
off  in  large  lamelliform  flakes. 

The  hair  of  the  affected  surfaces  often  becomes  white  or  falls  out, 
although  the  bleaching  of  the  hair  is  not  nearly  so  common  or  con- 
stant a  i)henomenon  as  has  been  described  by  many  writers.  There 
is  a  more  or  less  complete  suppression  of  the  sweat  secretion,  not 
only  of  the  anaesthetic  patches,  but  sometimes  of  the  skin  immedi- 
ately surrounding  them,  so  that  the  injection  of  i)ilocarpiue  does  not 
excite  the  glands  into  activity. 

The  patches  may  be  the  seat  of  a  violent  i)ruritus,  which  is  accen- 
tuated by  elevation  of  temperature  and  exercise,  or  ihej  may  become 
so  hyper^esthetic  as  to  give  the  sensation  of  a  superficial  burn.  They 
may  persist  for  years,  constituting  the  only  sign  of  the  disease  until 
the  appearance  of  certain  nervous  symptoms  indicates  irritative  or 
degenerative  changes  in  the  nerves. 

Like  the  exanthem  of  the  tubercular  form,  the  macules  have  a 
predilection  for  certain  regions  of  the  body.  Although  the  most  fre- 
quent sites  are  upon  the  face,  hands,  and  feet,  especially  about  the 
ankles,  they  may  appear  upon  the  back,  shoulders,  chest,  arms,  nates, 
thighs,  and  abdomen.  They  are  rarely  seen  upon  the  palms  and 
soles,  and  most  authorities  concur  in  the  statement  that  they  are 
never  seen  on  the  scalp.  This  statement  is  subject  to  modification. 
In  the  case  of  the  patient  shown  in  Fig.  7,  the  eruption  extends 
up  over  the  frontal  portion  of  the  hairy  scalp  to  the  vertex,  as  is  well 
shown  in  the  illustration. 

C.  W.  S ,  aged  47  years,  born  in  Bermuda.     Mother  living, 

in  good  health.  Father  died  at  sixty-five  (twenty-two  years  ago), 
the  patient  states,  of  some  kind  of  "  skin  disease"  of  many  years'  dura- 


508 


MOKROW — LEPROSY, 


tiou.  His  face  was  blotched,  his  lips  were  swollen,  the  lobes  of  the  ears 
hung  down,  and  he  is  reputed  to  have  had  syphilis.  The  mother  and 
father  had  lived  together  forty  years.  The  mother  is  now  living,  in 
good  health,  eighty-three  years  of  age.  Of  the  seven  children,  two 
brothers  and  two  sisters  died  of  lung  trouble.  The  youngest  child 
died  thirteen  or  fourteen  years  ago,  at  the  age  of  sixteen,  from  some 
form  of  skin  disease.  He  had  an  eruijtion  of  the  skin  and  swelling 
of  the  face  for  five  }ears  previous  to  his  death. 

The  patient  left  Bermuda,  at  the  age  of  seventeen  years,  to  become 
a  sailor.  He  visited  the  West  Indies,  the  Mediterranean,  was  in 
hospital  at  Constantinople  for  a  long  while,  and  made  several  voyages 


Fig.  7.— Leprosy  AlTeclitiK  the  Hairy  Scalp. 

to  Bombay  and  other  ])arts  of  the  East  Indies.  He  also  made  voy- 
ages to  various  West  Indian  and  South  American  jjorts.  He  came  to 
New  York  in  1883,  and  has  lived  here  since  continuousl}'  M'ith  the 
exception  of  a  few  trips  in  a  sailing-vessel  down  East. 

The  patient  first  noticed  a  spot  in  the  middle  of  the  forehead  just 
above  the  root  of  the  nose,  sixteen  years  ago.  It  remained  apparently 
stationary  for  a  long  time,  and  then  began  to  spread  gradually  down- 
wards over  the  nose,  cheek,  and  upper  lip,  and  upwards,  involviiig  the 
entii'e  surface  of  the  forehead  and  creeping  up  into  the  hairy  scalp  and 
downw^ards  again  to  the  junction  of  the  chin  with  the  neck.  Three  or 
four  years  ago  it  extended  behind  the  ear  and  upon  the  left  side.  For 
years  he  had  experienced  stinging  sensations  in  the  face,  and  about 
six  montlis  ago  he  noticed  a  numb  or  "dead  sensation,"  as  he  termed 


SYMPTOMS   OF  ANESTHETIC   LEPROSY.  509 

it,  over  the  entire  region  of  tlie  face.  The  eyelashes  have  entirely 
disappeared,  but  the  eyebrows  are  intact.  The  distribution  of  the 
eruption  over  the  right  side  of  the  cheek  and  forehead  and  extending 
up  into  the  hairy  scalj)  is  seen  in  the  accompanying  illustration  (Fig. 
7).  On  the  left  side  the  patch  has  extended  backwards  behind  the  ear 
to  a  point  half-wa}^  between  the  ear  and  the  occiput,  and  the  plainly 
defined  hyperchromatic  margin  sweeps  upwards  in  the  hairy  scalp, 
to  join  the  patch  on  the  right  side  shown  in  the  picture ;  it  extends 
downwards  to  the  middle  of  the  neck.  There  are  two  circular,  palm- 
sized  patches,  one  over  the  left  deltoid  region  and  one  on  the  antero- 
lateral surface  of  the  left  leg,  which  were  first  observed  eighteen 
months  ago ;  the  patient  thinks  that  they  were  then  about  the  same 
size  as  now.  There  is  also  a  large  circular  patch  beginning  at  the 
root  of  the  toes  and  embracing  within  its  area  almost  the  entire  instep 
of  the  right  foot.  The  patient  does  not  know  when  this  patch  first 
appeared.  He  noticed  twitching  of  the  muscles  of  the  toes  and  the 
loss  of  feeling  over  the  instep  of  the  right  foot  twelve  or  eighteen 
months  ago.  At  the  present  time  this  patch  is  almost  completely 
anaesthetic.  There  is  some  enlargement  of  the  peroneal  and  ulnar 
nerves.  He  has  noticed  for  a  year  or  more  that  upon  awakening  he 
finds  the  left  arm  asleep.  This  phenomenon  occurred  only  occasion- 
ally at  first,  but  now  it  is  frequently  observed  in  both  arms.  Ho  fre- 
quently upon  awakening  notices  the  fingers  of  both  hands  asleep,  the 
sensation  being  most  pronounced  in  the  little  and  ring  fingers. 

The  patient  had  syphilis  fifteen  years  ago,  and  an  attack  of  gon- 
orrhoea which  infected  his  left  eye  and  impaired  the  eyesight.  He 
had  epilepsy  until  twenty -five  years  ago.  After  an  attack  of  yellow 
fever  in  18G3  or  1864  from  infected  clothing  his  epileptic  seizures  dis- 
appeared, and  his  general  health  has  since  been  much  improved. 

The  changes  which  occur  in  the  evolution  of  the  lesions  give  them 
a  distinctive  character.  The  macules  may  remain  discrete  or,  spread- 
ing peripherally,  form  by  their  confluence  irregular  patches  with  poly- 
cyclic  outlines,  parts  of  circles  (Fig.  8),  or  large  gyrate  patches  with 
slightly  elevated  and  distinctly  defined  margins  and  pale,  pigmentless 
centres.  The  decolorization  of  the  centres  of  the  patches  with  the 
slightly  raised  hyperchromatic  margin  give  sthem  oftentimes  a  dis- 
tinctly annular  appearance.  This  process  of  blanching  may  extend 
over  large  surfaces  of  the  body.  Upon  the  limbs  the  patches  often 
exhibit  a  serpiginous  tendency,  gradually  extending  up  the  limbs  or 
spreading  over  the  joints. 

It  will  be  observed  that  the  centrifugal  tendency  which  charac- 
terizes the  extension  of  the  lesions  is  also  marked  in  the  retrogres- 
sive process,  which  invariably  begins  in  the  centre.  All  the  manifold 
changes  of  form  which  are  observed  in  the  macules  of  anaesthetic 
leprosy  are  effected  by  the  gradual  implication  of  the  surrounding 
healthy  skin  by  the  advancing  hyperchromia  with  the  constant  blend- 
ing of  their  contours  and  their  subsequent  partial  effacement. 


510 


MORBOW — LEPROSY. 


The  eruptiou  is  often  symmetrical,  but  avouIcI  seem  to  be  indepen- 
dent of  the  distribution  of  jiarticular  nerves.  In  certain  cases  the 
macnlje  are  dispersed  along  the  intercostal  nerves,  forming  a  double 
zona  which  is  absolutely  painless. 

Eiiipfiiiii  <if  liiiU'i^. — Allusion  has  already  been  made  to  the  fact 
that  a  bullous  erujition  may  be  among  the  earliest  cutaneous  manifes- 
tations of  leprosy ;  at 
a  later  stage  of  the 
disease  it  constitutes 
a  characteristic  and 
by  no  lueans  uncom- 
mon symptom.  The 
ai)pearance  of  bullBe 
may  be  preceded  by 
symptoms  of  general 
disorder,  fever,  and 
neuralgic  pains,  or 
they  m  a  y  develop 
without  any  premoni- 
tory symptoms.  In 
one  patient  of  mine 
bullae  appeared  along 
the  anterior  lateral 
aspect  of  the  right 
leg,  one-half  dozen  or 
more  in  number,  as 
the  first  cutaneous 
expression  of  the  dis- 
ease. 

The  bulipe  vary 
in  size  from  that  of  a 
small  pea  to  that  of  a 
cherry  or  larger,  and 
the  individual  lesions 
resemble  somewhat 
in  appearance  those 
of  pemphigus  vulgaris.  The  epidermal  walls  are  first  distended 
by  the  effusion  of  a  pale  yellowish  serum,  and  the  bullae  may  in- 
crease in  size  and  their  contents  become  purulent ;  they  may  under- 
go spontaneous  rupture  after  a  few  days,  and  their  flaccid  walls  may 
be  wiped  or  brushed  away,  leaving  slight  reddish  spots  or  slight 
pigmented  stains  which  soon  clear  up. 

Instead  of  this  rapid  involution  the  bullae  may  increase  in  size,  the 


Fig.  fc.— Macular  Lesions  of  Aneesthetic  Leprosy. 


SYMPTOMS   OF  AN.^STHETIG   LEPROSY.  511 

contents  become  purulent  and  concrete  in  tlie  form  of  yellowish-green 
or  brownish  crusts,  which  when  removed  reveal  excoriations  more  or 
less  profound,  and  superficial  ulcers ;  the  latter,  on  cicatrizing,  leave 
prominent  scars  which  are  at  first  pigmented  and  later  become  white, 
smooth,  and  shining  and  frequently  bordered  by  a  darkly  pigmented 
ring.  The  blebs  may  succeed  one  another  for  several  years  or  during 
the  whole  course  of  the  disease  without  being  accompanied  by  any 
notable  disorder  other  than  the  neuralgic  or  rheumatoid  pains.  At  a 
later  stage  the  ulcers  not  infrequently  persist,  increase  in  area  and 
depth,  and  constitute  the  starting-point  of  deep-seated  ulcers  and 
mutilations. 

The  so-called  lepra  lazarine,  which  is  common  in  certain  countries, 
as  in  Mexico,  and  which  has  been  described  by  certain  observers  as 
a  distinct  form  of  leprosy,  represents  only  a  variety  of  this  bullous 
eruption.  There  is  in  this  phlyctenular  eruption  a  slow  formation 
of  blebs  w^hich  present  the  appearance  of  a  slightly  raised,  parch- 
ment-like covering,  involving  the  epidermis  and  superficial  layers  of 
the  derma,  which  are  distended  by  a  serous  accumulation  (pem- 
phigus escharotica).  When  this  eschar  is  detached  it  leaves  an 
ulcerated  surface,  with  grayish  fungoid  base  and  jjerpendicular  sides, 
which  may  either  be  persistent  and  extend  in  depth  or  be  complicated 
with  gangrene  and  lead  to  mutilation  (Leloir). 

The  points  of  predilection  for  the  bullse  are  the  backs  of  the  hands 
and  feet,  heels,  back  of  the  elbow,  and  the  anterior  surface  of  the 
knees,  although  they  may  be  found  on  any  j^ortion  of  the  external 
integument.  It  is  evident  that  these  parts  are  more  particularly  ex- 
posed to  rubbing  and  irritation  from  contact  of  all  kinds.  Impey 
believes  that  the  buUse  are  merely  accidental  phenomena  caused  by 
external  injury  and  not  essentially  an  expression  of  the  leprous  proc- 
ess.    He  asserts  that  they  do  not  contain  bacilli. 

The  results  of  the  bacteriological  examinations  which  have  been 
made  to  determine  the  presence  or  absence  of  bacilli  in  the  pemphi- 
goid lesions  of  leprosy  are  contradictory.  Kalindero,  Petrini,  Aristid 
Bey,  and  others  assert  that  they  have  found  bacilli,  though  in  small 
numbers  and  not  constantly,  both  in  the  crojos  of  bullae  which  come 
out  spontaneously,  and  in  the  liquid  secretions  of  the  blebs  which 
were  produced  artificially  in  lepers  by  the  application  of  vesicatories. 
These  results  have  been  contested  by  other  observers  who  failed  to 
find  bacilli  in  the  bullae.  The  general  impression  has  always  been  that 
the  bullae  of  leprosy  were  caused  by  the  action  of  the  toxins  rather 
than  directly  by  the  bacilli.  Leloir  has  seen  bullae  form  in  the  mu- 
cous membranes. 

Trophic  Changes  of  the  Glands. — Coincident  with  the  development 


512  MORROW — LEPROSY. 

of  the  patches  certain  changes  take  place  in  the  glandular  apparatus  of 
the  skin.  These  changes  are  first  noticed  in  the  surfaces  occupied  by 
the  eruption,  but  later  may  affect  the  entire  skin.  The  hairs  of  the 
affected  surface  suffer  in  their  nutrition.  The  dystrophic  change  may 
be  manifest  in  the  bleaching  or  whitening  of  the  hairs,  which  become 
thin,  wasted,  and  lanugo-like,  but  may  or  may  not  fall  out.  A  simi- 
lar process  of  bleachiug  of  the  hairs  has  been  observed  by  Weir 
Mitchell  upon  the  hands  and  fingers  in  cases  of  "glossy  skin."  It 
has  been  noted  that  the  hairs  may  reappear  upon  the  patches  from 
which  they  have  disappeared.  This  regeneration  is  always  coinci- 
dent with  other  evidences  of  improvement  in  local  nutrition. 

The  Sudoriparous  Glands. — Keference  has  alreadj'  been  made  to 
the  abnormal  activity  of  the  sweat  glands  during  the  invasion  period. 
This  hyperidrosis  is  invariably  succeeded  b\'  a  diminution  and  finally 
a  complete  suppression  of  the  sweat  function.  These  anomalies  are 
due  to  trophic  changes  in  the  glands,  caused  b}^  the  action  of  the  bacilli 
or  their  toxins  upon  the  peripheral  nerves.  Weir  Mitchell  has  de- 
scribed a  precisely-  similar  condition  in  the  "  glossy  skin"  resulting 
from  severe  nerve  injury,  in  which  there  was  a  marked  hyperidrosis 
affecting  the  parts  supplied  by  the  nerve,  followed  by  a  complete 
anidrosis.  The  anidrosis  is  at  first  confined  to  the  macular  lesions 
and  may  be  so  complete  that  the  injection  of  pilocarpine  fails  to  stim- 
ulate their  functional  activity.  The  secretion  is  sometimes  completely 
suppressed  over  the  surface  of  the  patches,  while  the  surrounding 
skin  sweats  freely.  I  have  observed,  in  a  patch  situated  upon  the 
heel  and  side  of  the  foot,  that  while  the  central  portion  was  absolutely 
dry,  there  was  a  hypersecretion  around  the  peripheral  border  which 
appeared  in  the  shape  of  small  beads  of  moisture,  while  there  was 
no  sensible  perspiration  in  the  healthy  surrounding  skin.  It  would 
seem  that  in  the  evolution  of  some  of  these  patches,  the  trophic 
changes  are  manifested  in  the  central  portion  by  achromia,  anaes- 
thesia, and  anidrosis,  while  hyperchromia,  hyperaesthesia,  and  hy- 
peridrosis are  marked  at  the  periphery.  After  a  certain  period  the 
sweat  secretion  becomes  more  or  less  diminished  or  completely  sus- 
pended over  the  general  surface  of  the  body.  In  one  of  my  cases 
there  was  observed,  during  the  summer,  marked  hyperidrosis  of 
the  scalp,  which  was  probabl}'  compensatory  to  a  certain  degree  for 
the  diminished  secretion  of  the  general  surface.* 

*  On  a  visit  to  Molokai,  several  j'ears  ago,  T  observed  this  phenomenon  in  a  very 
marked  degree  in  two  anaesthetic  but  not  disabled  lepers  who  carried  my  baggage  to 
the  top  of  the  pali  which  shut  in  the  leper  settlement.  After  a  fatiguing  climb  the 
sweat  poured  from  the  scalp  and  ran  down  their  faces  in  little  rivulets,  while  the  per- 
spiration from  the  hands,  arms,  and  other  exposed  surfaces  was  hardly  noticeable. 


SYMPTOMS  OF  ANESTHETIC  LEPROSY.  513 

The  sebaceous  glands  also  become  atrophied  and  altered  in  their 
function.  The  secretion,  which  was  at  first  exaggerated,  becomes  en- 
tirely suppressed.  At  a  more  advanced  stage,  when  the  sweat  and 
sebaceous  glands  are  destroyed  and  there  is  a  complete  arrest  of  their 
functions,  the  skin  of  the  general  surface  of  the  body  becomes  dry, 
parchment-like,  and  harsh  to  the  feel.  The  epidermis  readily  cracks 
and  fissures,  and  the  breaks  in  its  continuity  not  infrequently  become 
the  starting-points  of  superficial  or  deep  ulcerations.  It  may  be  re- 
marked that  very  often  the  skin  of  lepers,  especially  that  of  the  hands, 
becomes  dry,  shiny,  or  glossy  from  atrophic  changes,  simulating  the 
"glossy  skin"  of  Paget. 

Sensory  Disorders. 

For  many  years  the  cutaneous  eruptions  may  constitute  the  only 
exterior  manifestations' of  ansesthetic  leprosy.  But  during  this  period 
and  throughout  the  entire  course  of  the  disease  there  are  certain  modi- 
fications of  sensibility  which,  in  order  to  prevent  repetition  in  their 
description,  may  be  conveniently  considered  together  under  this 
heading. 

In  the  ordinary  conception  of  anaesthetic  leprosy  the  most  impor- 
tant clinical  feature  is  expressed  in  the  name  by  which  this  form  of 
the  disease  is  designated.  While  anaesthesia  is  an  essential  and  fun- 
damental feature  of  nerve  leprosy,  and  indeed  constitutes  the  most 
pathognomonic  sign  from  a  diagnostic  point  of  view,  there  are  numer- 
ous modifications  of  sensibility  which  are  scarcely  less  interesting 
and  important.  In  many  cases  the  nature  of  the  skin  lesions  is  ab- 
solutely indeterminable  without  the  indic^itions  furnished  by  the 
sensory  disorders. 

In  many  cases  the  sensory  disorders  constitute  the  only  certain 
element  of  diagnosis,  as  is  well  illustrated  in  a  case  which  came 
under  my  observation  about  ten  years  ago.  The  following  notes  were 
taken  at  that  time : 

In  this  patient  the  eruption  began  nearly  five  years  ago  as  a  small 
red,  somewhat  itchy  spot  on  the  anterior  surface  of  the  left  foot  at 
the  base  of  the  great  toe.  It  enlarged  slowly  and  almost  impercepti- 
bly. After  a  time  it  cleared  in  the  centre  while  extending  peripher- 
all3\  At  the  present  time  it  involves  almost  the  entire  upper  part  of 
the  under  surface  of  the  foot.  The  hyperchromatic  margin  may  be 
seen  extending  along  the  root  of  the  toes  and  advancing  with  a  circi- 
nate  sweep  along  the  outer  aspect  of  the  foot  upwards  to  the  ankle- 
joint,  crossing  the  instep  and  continuing  down  under  the  instep  and 
the  inner  half  of  the  sole,  and  emerging  upon  the  integument  of  the 
first  phalanx  of  the  great  toe.  The  margin  is  irregularly  scalloped, 
slightly  elevated,  one-quarter  to  one-half  an  inch  in  width,  and  of  a 
Vol.  XVIII.— 33 


514  MORROW — LEPROSY. 

browiiisli  or  lilac  tiut.  The  central  portion  presents  a  bluish-graj 
tint,  the  coloration  depending  upon  tlie  atrophy  of  the  skin,  through 
which  the  superficial  vessels  are  more  apparent. 

Upon  the  anterior  inner  aspect  of  the  leg,  at  the  junction  of  the 
middle  and  upper  thirds,  there  is  a  patch  two  inches  iu  diameter  which 
began  three  years  ago.  The  centre  is  faintly  pigmented,  the  margin 
made  up  of  brownish-red  puncta,  and  partly  of  diffused  redness.  These 
minute  points  seem  to  represent  infiltration  of  the  follicles.  This 
patch  is  anfesthetic  iu  the  centre.  Above  the  external  malleolus  there 
are  two  irregularly  circular  macules,  each  about  the  size  of  a  silver 
quarter,  which  made  their  appearance  about  two  years  ago.  The 
centre  is  beginning  to  clear,  though  still  pigmented,  the  margin  is  of 
a  deeper,  more  brownish-red.  But  slight  impairment  of  sensation 
can  be  detected  iu  these  more  recent  patches. 

In  the  central  portion  of  the  older  patch  there  is  comjilete  loss  of 
the  pain  and  temperature  sense.  The  tactile  sense  is  but  slightly  im- 
l)aired,  and  the  muscular  sense  is  apparently  unchanged,  while  just 
beyond  the  liyper?estlietic,  hyperchromatic  margin  normal  sensibility 
is  preserved  in  absolute  integrity'.  Were  it  not  for  the  element  of 
anaesthesia,  I  believe  it  would  be  impossible  to  diagnosticate  the 
nature  of  this  eruption.  This  patient  has  apparently  entirely  recov- 
ered. 

We  have  seen  that  the  invasion  period  is  characterized  by  hyper- 
8Bsthesia,  pruritus,  neuralgic  pains,  and  other  symptoms  which  indi- 
cate that  the  nervous  system  is  the  i:)rimary  seat  of  the  disease.  The 
pathological  basis  of  these  phenomena  is  now  recognized  to  be  a  spe- 
cific neuritis,  i)arenchymatous  and  interstitial,  which  attacks  the 
peripheral  nerves  and  leads  to  their  more  or  less  complete  degenera- 
tion. The  sensory  disorders  of  nerve  leprosy  are  not,  therefore,  pure 
neuroses,  but  rather  trophoneuroses,  since  they  are  always  consecu- 
tive to  irritation  and  degeneration  of  the  terminal  filaments  of  the 
cutaneous  nerves  or  some  portion  of  the  sensory  conducting  appara- 
tus. Recent  investigations  would  seem  to  show  that  the  primary 
action  of  the  bacilli  is  exerted  upon  the  nerve  terminals,  and  as  these 
constitute  an  integral  i^art  of  the  skin,  the  sensory  disturbances  may 
be  regarded  as  due  to  trophic  influences.  The  sensory  disorders  may 
be  associated  with  trophic  changes,  or  they  may  occur  without  obvi- 
ous structural  changes  in  the  skin. 

These  modifications  of  sensibility  may  be  divided,  according  to 
the  usual  order  of  their  development,  into  (1)  exaltations  of  sensibil- 
ity, expressed  in  hyperaesthesia,  pruritus,  dermatalgia,  and  neuralgic 
pains ;  (2)  perversions  of  sensation^  which  consist  of  various  dysses- 
thesias,  sensations  of  needles  and  pins,  numb  and  dead  feelings  of  the 
limbs,  delayed  or  retarded  sensation,  etc. ;  (3)  abolition  of  sensation, 
more  w  less  complete,  expressed  iu  anaesthesia  or  disassociation  of  the 
modes  of  sensation,  etc. 


SYMPTOMS   OF   ANESTHETIC  LEPROSY.  515 

The  first  group  corresponds  to  tlie  period  of  irritation  of  the 
nerves  which  may  be  exceedingly  prolonged  in  duration. 

The  second  group  marks  the  period  which  intervenes  between  the 
cessation  of  the  irritative  neuritis  and  the  complete  disorganization  of 
the  nerve  fibres.  The  nerves  are  in  a  state  of  stupor  in  which  the 
sensation  is  delayed  but  not  extinguished.  Even  at  this  period  there 
may  be  some  evidences  of  disassociation  of  connected  sensations. 

The  third  group  corresponds  to  the  complete  disorganization  of 
the  nerves  which  serve  as  a  medium  of  nutrition  and  sensation.  It 
may  be  practically  indefinite  in  duration. 

The  first  effect  of  the  neuritis  is  irritation  of  the  part  supplied  by 
the  affected  nerve  and  may  consist  of  tingling,  of  formication,  of  a  sen- 
sation of  heat  or  cokl,  or  of  r  tinging  or  burning  at  the  surface  of  the  skin 
or  along  the  course  of  the  nerve.  The  sensation  is  sometimes  likened 
to  that  caused  by  an  abraded  surface  which  is  exposed  to  contact  with 
air  or  water.  One  of  my  patients  would  take  off  his  shoe  repeatedly, 
feeling  sure  that  the  smarting  sensation  felt  along  one  side  of  the  heel 
was  due  to  the  epidermis  being  rubbed  off.  One  manifestation  is  in 
the  form  of  localized  itching,  which  frequently  affects  the  palms  of 
the  hands  or  soles  of  the  feet ;  it  may  occur  in  any  portion  of  the 
limbs.  It  is  apparently  more  deeply  seated  than  in  ordinary  pru- 
ritus or  in  the  pruritus  of  eczema.  It  is  often  persistent  and  torment- 
ing and  is  relieved  by  grasping,  compressing,  or  pinching  the  parts 
rather  than  by  scratching. 

The  dermatalgia  is  sometimes  described  asared.-hot,  burning  pain. 
Any  blow  or  pressure  or  even  slight  contact  may  cause  a  shock  like 
that  from  an  electric  battery,  which  is  felt  to  course  along  the  affected 
limb.  In  one  of  my  cases,  upon  merely  rubbing  the  skin  or  slightly 
scratching  over  the  anterior  surface  of  the  wrist,  there  was  felt  a  tin- 
gling, radiating  along  the  entire  course  of  the  forearm.  This  condi- 
tion persisted  for  months. 

In  another  case  painful  smarting  sensations  were  felt  over  the 
anterior  lateral  aspect  of  the  right  leg  in  the  immediate  neighborhood 
of  a  pigmented  patch.  This  continued  three  or  four  weeks  and  sud- 
denly disappeared.  All  of  these  subjective  symptoms  may  develop 
suddenly.  They  are  exceedingly  capricious,  being  manifest  for  a 
variable  length  of  time  and  disappearing  with  the  same  facility  with 
which  they  appeared.  For  weeks  or  months  they  may  be  entirely 
absent. 

The  hypersesthesia  is  sometimes  experienced  in  the  greatest  in- 
tensity in  the  face.  Neuralgic  pains  may  be  felt  along  the  course  of 
the  trifacial  or  along  the  ulnar,  sciatic,  and  peroneal  nerves,  affecting 
the  forearms,  hands,  the  entire  leg,  feet,  and  toes.     Locomotion  is 


516  MORROW — LEPROSY. 

often  difficult  and  painful.  The  patient  may  feel  as  if  he  were  walk- 
ing on  pebbles  or  broken  glass.  One  patient  describes  the  sensatiou 
"as  if  he  were  walking  on  stone  bruises." 

The  pains  instead  of  being  superficial  may  be  of  a  deep,  boring, 
lancinating  character,  as  if  deep  down  in  the  tissues.  They  are 
paroxysmal  in  character  and  are  particularly  nocturnal.  They  may 
be  so  accentuated  as  to  be  atrocious,  almost  unendurable,  depriving 
the  patient  of  sleep,  and  the  countenance  often  takes  on  an  expression 
of  habitual  suffering. 

As  the  irritative  neuritis  is  succeeded  by  degenerative  changes  in 
the  nerves,  these  exaltations  of  sensibility  cede  to  a  gradual  dulling 
of  sensation  and  more  or  less  complete  insensibilit}'. 

Many  years  may  i>ass,  and  the  patient,  with  the  exception  of  out- 
breaks of  new  eruptions  of  macules  or  bullie  and  occasional  neuralgic 
pains,  may  have  no  disorders  of  sufficient  importance  to  awaken  his 
suspicions  as  to  the  exceeding  gravity  of  the  disease  with  which  he  is 
afflicted.  During  this  period  there  are  usually'  observed  inflammation 
and  enlargement  of  the  peripheral  nerves  which  become  more  pro- 
nounced as  the  disease  progresses. 

In  the  invasion  of  the  nervous  system  the  bacilli  seem  to  manifest 
a  predilection  for  the  ulnar  and  peroneal  nerves.  The  nerves  which 
are  most  constantly'  and  characteristically  involved  are  the  ulnar, 
peroneal,  and  median.  Second  in  point  of  frequency  are  the  facial 
branches  of  the  seventh  pair  and  the  first  division  of  the  fifth.  It  is 
worthy  of  note  that  the  nerves  primarily  involved  are  those  which  are 
most  superficially  situated  and  therefore  most  exposed  from  their  sit- 
uation and  sun'oundings  to  external  influence. 

Why  the  bacilli  show  a  predilection  for  certain  nerves — the  ulnar, 
for  example,  instead  of  the  radial  —has  not  been  determined.  The 
ulnar  nerve  is  not  invariably  the  first  to  be  affected,  and  the  bacilli  may 
begin  their  depredations  in  any  particular  branch  of  the  predilected 
nerve.  The  thickening  of  the  ulnar  nerve  which  may  often  be  felt 
behind  the  olecranon,  giving  the  sensation  of  a  tense  cord  rolling 
beneath  the  fingers,  is  one  of  the  earliest  and  most  valuable  signs  of 
nerve  lepros}'.  In  doubtful  cases,  when  other  symptoms  are  equivo- 
cal, its  presence  furnishes  the  necessary  confirmation  of  the  diagnosis. 

The  interstitial  neuritis  may  manifest  itself  in  the  form  of  a  diffuse 
uniform  enlargement,  and  the  nerve  may  attain  the  size  of  the  little 
finger.  The  thickening  may  be  fusiform  or  more  nodular  or  monili- 
form.  This,  according  to  Leloir,  is  characteristic  of  the  ulnar  modi- 
fication. It  is  exceedingly  sensitive  to  the  touch,  and  pains  may  be 
felt  radiating  along  its  course  to  the  fingers.  At  a  later  stage,  when 
degeneration  is  complete,  it  does  not  permanently  conserve  its  vol- 


SYMPTOMS  OF  ANESTHETIC  LEPROSY.  517 

■nme.  There  is  a  diminution,  not  only  in  size,  but  in  sensitiveness. 
It  may  be  forcibly  compressed  without  provoking  radiating  pains 
in  the  region  of  its  peripheral  expansion. 

For  a  long  period  there  is  noticeable  a  disposition  of  the  hands  to 
go  to  sleep,  at  first  from  pressure  from  lying  upon  them ;  later  the 
numb  sensation  may  occur  without  this  pressure.  This  tendency-  of 
the  limbs  to  go  to  sleep  is  especially  marked  at  night,  possibh^  from 
greater  exposure  to  pressure  of  the  arms  from  the  posture  assumed  in 
lying.  The  i)atient  wakes  from  a  sound  sleep  finding,  it  may  be,  the 
little  and  ring  fingers  closed  and  asleep.  At  another  time  the  fingers 
supplied  by  the  median  may  be  found  closed  and  numb,  and  again 
the  fingers  of  the  entire  hand.  Similar  sensations  are  often  felt  in 
the  toes,  more  often  in  the  great  toe  than  in  the  small  toes.  It  is 
noticeable  that  they  return  to  the  normal  condition  without  the  sen- 
sation of  "pins  and  needles."  In  one  of  my  patients  the  awakening 
was  described  as  waves  of  sensation  passing  along  the  forearms  into 
the  fingers.  Usually  upon  extending  and  flexing  the  fingers  several 
times,  sensation  returned  more  or  less  promptly.  At  a  later  stage  the 
patient,  on  awakening,  found  the  fingers  flexed  and  absolutely  insen- 
sitive, and  it  was  necessary  to  use  the  other  hand  to  overcome  the 
flexion.  After  working  the  fingers  for  a  few  minutes  backward  and 
forward  sensation  returned.  It  is  evident  that  this  sensation  of 
numbness  and  deadness  is  to  be  differentiated  from  anaesthesia,  as 
the  patient  is  conscious  of  it  from  his  own  feelings.  A  patient  does 
not  know  he  is  anaesthetic  until  it  is  revealed  to  him  by  some  means 
outside  of  his  own  consciousness. 

During  this  period  the  acuity  of  the  tactile  sense  is  dulled,  and 
pins  and  small  articles  cannot  be  easih^  picked  up.  Articles  are 
readily  dropped,  from  tremor  or  weakness  or  inability  to  hold  things 
firmly  by  the  hand.  The  fingers  lose  their  deftness  for  any  form 
of  mechanical  technique.  There  is  marked  evidence  of  muscular 
atroj)hy  and  disturbance  in  the  coordination  of  the  muscles.  The 
handwriting  becomes  changed,  jerky,  tremulous,  and  irregular.  In 
performing  any  manual  work  which  requires  dexterity,  the  patient 
cannot  do  it  from  force  of  habit,  and  the  guiding  and  directing  influ- 
ence of  the  eye  must  be  applied  for  its  proper  accomplishment. 

Hillis,  whose  careful  personal  study  of  leprosy  in  British  Guiana 
gives  his  observations  an  especial  value,  says  that  many  of  the  negro 
field  laborers  have  their  attention  first  directed  to  their  condition 
owing  to  the  difficulty  they  find  in  holding  a  cutlass.  This,  he 
thinks,  is  not  so  much  from  loss  of  sensation  in  the  parts  as  from  a 
want  of  coordinating  power  or  muscular  weakness,  which  amounts  in 
some  cases  to  a  general  tremor  or  shaking  of  the  limbs.     "  Shooting 


518  MORROW— LEPROSY. 

paius  or  au  uudue  seusitiveuess  are  nearly  always  felt  iu  the  fiugei-a 
and  toes  before  these  parts  are  affected."  In  a  case  reported  by  Thin, 
a  butcher  suffering  from  nerve  leprosy  stated  that  the  first  symptom 
he  observed  in  himself  was  a  strange  loss  of  power,  as  he  expressed 
it,  when  cutting  meat  in  the  market.  In  another  case,  reported  by 
Dejerine,  a  French  soldier  who  had  served  for  eighteen  months  in  the 
Tonquin  was  discharged  from  the  service  for  inability  to  handle  his 
gun. 

Another  phenomenon  which  marks  the  transition  into  complete 
insensibility  is  retardation  of  sensation.  It  has  been  observed  that 
in  applying  the  electric  current  there  may  be  quite  an  api)reciable 
time  before  the  sensation  becomes  distinct.  The  sensation  does  not 
at  once  attain  its  maximum,  but  gradually  gains  iu  intensity  during 
twenty  or  thirty  seconds. 

With  this  slowness  iu  the  transmission  of  sensation  certain  perver- 
sions of  sensation  may  be  associated.  Jeanselme  found  that  if  a  hot 
body  or  a  piece  of  ice  is  applied  over  a  i)atch  it  causes  at  first  the 
simple  impression  of  contact.  If  the  exi)eriment  is  continued,  a  sen- 
sation of  heat  or  cold  is  finally  felt,  feebly  and  only  after  a  long  time. 
If  now,  on  the  part  where  the  ice  has  been,  a  moderately  cold  sub- 
stance is  applied,  the  patient  is  deceived  and  complains  of  a  sensa- 
tion of  heat. 

It  is  through  this  transition  stage  that  the  nerves  pass  into  a  stage 
of  complete  insensibility.  Anaesthesia  develops  gradually.  It  is 
commonly  noticeable  at  first  in  the  patches,  especially  over  the  decol- 
orized centres,  and  is  often  coincident  with  hyjjeraBsthesia  of  the 
hy  perchromatic  borders.  It  may  develop  in  regions  not  the  seat  of  the 
patches  and  so  insensiblv  that  the  patient  is  not  aware  of  it.  The 
])atient  does  not  feel  the  objects  he  grasps.  He  may  not  feel  the  heat 
of  the  pipe  held  in  his  hand  or  cuts  made  in  shaving.  One  may  stick 
a  pin  or  needle  into  the  patch  without  the  patient's  knowledge.  Iu 
walking,  the  sensation  has  been  comjiared  to  stepping  on  cotton,  wool, 
or  a  thick  carpet.  The  patient  may  walk  barefoot  on  rock,  gravel,  or 
thorns  without  feeliug  the  wounds  they  make.  The  insensibility  is 
so  complete  that  grave  operations  may  be  performed  without  any  sen- 
sation of  pain.  Instances  have  been  known  in  which  the  patient  has 
chopped  off  the  finger  or  toe  which  annoyed  him  without  feeling  pain. 

Many  of  the  cutaneous  lesions  encountered  in  nerve  leprosy  before 
the  mutilating  stage  sets  in  are  due  to  the  sus]jended  sensibilitA . 
The  deadened  nerves  give  no  warning  through  the  i)ercex)tion  of  pain 
to  the  inroads  of  heat,  cold,  or  other  injuries.  The  patient  often 
receives  a  severe  injury,  or  a  knife  may  be  thrust  into  the  anaesthetic 
I)atch  without  any  sensation  being  caused. 


SYMPTOMS   OF   ANESTHETIC   LEPROSY.  519 

Sensibilitj  to  puncture  is  variable,  not  only  in  cliflferent  j^arts,  but 
in  contiguous  spots ;  the  same  is  true  of  sensitiveness  to  temperature. 
Quinquaud  found  by  means  of  a  very  delicate  sesthesiometer  com- 
bined ^vitli  a  dynamometer  that,  while  5  gm.  in  one  point  would 
elicit  distinct  sensation,  it  would  require  100  gm.  2  mm.  distant  from 
the  first  point,  to  call  forth  the  same  degree  of  feeling.  With  regard 
to  temperature,  it  was  sometimes  necessary  to  obtain  30"^  C  before 
obtaining  a  sensation;  or  0°  C  and  10°  C.  would  be  contiguous  find- 
ings. There  were  frequent  phenomena  of  disassociation.  Some 
patients  had  no  perception  of  cold,  but  felt  heat,  and  vice  versa.  Anal- 
gesia and  thermo-anaesthesia  may  be  present  with  or  without  impair- 
ment of  the  tactile  sense.  While  the  loss  of  the  pain  sense  is  often 
so  complete  that  the  thrust  of  a  pin  into  the  affected  part  may  occa- 
sion no  pain,  simple  contact  by  gently  rubbing  the  surface  may  lie 
readily  appreciated.  This  disassociation  of  the  modes  of  sensibility 
is  characteristic  of  leprosy. 

The  individual  independence  of  the  different  modes  of  sensation 
which  are  normally  connected  is  established  by  studying  cases  in 
which  each  of  them  appears  isolated.  In  the  anaesthetic  jjatch  of 
leprosy  we  find  that  a  certain  part  of  the  skin  cannot  discriminate 
between  heat  and  cold,  another  part  is  deprived  of  the  sense  of  touch, 
and  that  though  a  third  part  maj^  have  the  sense  of  feeling  injury  to  it 
does  not  cause  pain.  It  is  worthy  of  note  that  hyper^esthesia  may  be 
manifest  at  an  advanced  stage  of  the  disease,  and  it  is  frequently  pres- 
ent in  close  proximity  to  the  region  that  is  absolutelj'  anaesthetic.  I 
have  observed  a  number  of  times  in  applying  electricity'  that  a  cur- 
rent representing  the  full  strength  of  fifty  elements  and  of  sufficient 
intensity  to  char  the  tissues  when  passed  through  a  wire  brush,  occa- 
sioned no  sensation  of  pain  in  the  central  portion  of  the  patch.  In 
the  zone  just  within  the  hyperaemic  margin,  one-half  this  strength 
would  pass  for  a  fraction  of  a  minute  without  evoking  any  sensation, 
and  then  the  nerve  conductivity  would  be  aroused,  shown  by  a  sharp 
sensation  of  pain,  so  that  the  strength  of  the  current  would  have  to  be 
largely  reduced  to  make  it  bearable.  In  the  hyperaemic  margin  of 
the  patch  it  required  a  smaller  current  to  provoke  sensation  than 
upon  the  healthy  sound  skin. 

It  is  worthy  of  note  that  while  anaesthesia  is  the  most  durable 
symptom  of  nerve  leprosy,  sensation  may  return  to  surfaces  formerly 
occupied  by  anaesthesia,  or  indeed  it  may  very  exceptionally  be 
replaced  by  hyperaesthesia.  The  interpretation  of  the  rationale  of 
this  retrogressive  phase  of  the  disease  is  not  determined.  It  may  be 
that  not  all  of  the  fibres  are  destroyed  and  the  power  of  conductivity 
which  was  held  in  abeyance  is  restored,  or  it  may  be  that  the  nerve 


520  MORROW — LEPROSY. 

fibres  are  regenerated  and  this  restoration  is  followed  by  recovery  of 
their  physiological  activity. 

Jeanselme  has  made  a  special  study  of  the  mode  of  progression 
of  auitsthesia,  its  topographical  distribution,  and  its  qualitative  al- 
terations, the  results  of  wliich  may  be  formulated  as  follows : 

1.  The  distribution  of  anaesthesia  in  leprosy  is  manifestly  sym- 
metrical. When  insensibility  affects  one  member,  it  will  soon  attack 
the  homologous  member.  In  addition  the  anaesthesia  is  ordinarily 
distributed  in  an  almost  equal  manner  over  the  four  extremities. 
Likewise  the  anaesthesia  of  the  lower  extremities  is  more  extensive 
and  more  precocious  than  that  of  the  upper  extremities.  In  syr- 
ingomyelia, on  the  other  hand,  the  anaesthesia,  often  symmetrical,  is 
generally  predominant  in  the  u])per  extremities;  it  may  even  be  situ- 
ated exclusiveh'  here. 

2.  Anaesthesia  begins  at  the  level  of  the  free  extremity  of  the  mem- 
bers and  mounts  gradually  upward  to  their  root.  Sensation,  almost 
extinct  in  the  hand  or  foot,  is  only  dulled  in  the  arm  or  thigh. 

3.  Anaesthesia  of  the  deep  parts  of  the  derma  is  in  general  less 
marked  and  of  later  development  than  that  of  the  sui^erficial  parts. 
As  the  anaesthesia  progresses  it  descends  lower  and  lower  in  the  skin. 
At  first  the  mantle  of  anaesthesia  which  covers  the  insensible  region 
is  (^uite  thin ;  a  needle  pushed  horizontally  into  the  papillary  body 
provokes  no  pain,  but  the  patient  protests  as  soon  as  the  puncture 
involves  the  deeper  part  of  the  skin.  Still  later  the  skin  becomes  com- 
pletely insensible  and  may  be  pierced  entirely  through  without  pain. 

4.  The  anaesthesia,  which  is  at  first  of  ribbon  form,  tends  to  take 
on  later  the  segmentary  type.  In  the  upi^er  limb  it  occupies  at  first 
the  little  finger  and  the  ulnar  border  of  the  hand,  and  forms  along 
the  postero-internal  portion  of  the  arm  and  forearm  a  long  band; 
this  ascends  to  a  variable  height,  often  to  the  elbow,  sometimes  to  the 
axilla,,  the  sensibility'  of  which  always  remains  intact. 

In  the  lower  limb  the  anaesthesia  first  afi'ects  the  great  toe  and  the 
internal  border  of  the  foot,  sometimes  the  external  border.  At  the 
same  time  a  long  band  of  anaesthesia  commencing  at  the  base  of  the  leg 
ascends  more  or  less  high  upon  the  external  aspect  of  the  leg,  attain- 
ing the  knee,  the  middle  of  the  thigh,  or  even  the  region  of  the  tro- 
chanter, upon  which  it  widens  en  raquetfe.  Sooner  or  later  the  prim- 
itive band  of  insensibility  spreads  out  and  forms  a  gutter,  the  two 
lips  of  which  finally  close  together.  The  limb  is  then  encased  in  a 
sheath  of  anaesthesia. 

5.  The  segmentary  anaesthesia  of  leprosy  differs  in  its  essential 
characters  from  the  segmentary  anaesthesia  of  syringomyelia.  From 
an  attentive  observation  of  patients  or  from  the  indications  furnished 


SYMPTOMS  OP  ANESTHETIC  LEPROSY.  521 

by  the  first  phases  of  the  anaesthesia  one  arrives  at  the  conviction  that 
in  its  debut  the  insensibility  has  been  of  the  ribbon  form. 

6.  The  anaisthesia  does  not  occupy  the  zone  of  peripheral  distri- 
bution of  a  nerve  trunk;  the  ribbon-like  disposition  seems  to  be 
determined  by  an  alteration  of  the  posterior  roots  or  of  the  cord. 

7.  The  anaesthesia  of  the  face  and  of  the  trunk,  without  being 
rare  in  leprosy,  is  less  frequent  than  that  of  the  members.  It  does 
not  form  a  mask  or  a  vest  neatly  limited  around  the  body. 

8.  In  the  beginning  all  the  modes  of  sensibility  are  not  simulta- 
neously abolished ;  the  thermo-analgesia  far  outstrips  in  its  develop- 
ment the  tactile  anaesthesia.  At  an  advanced  period  the  imperfect 
disassociation  of  sensibility  gives  place  to  complete  anaesthesia.  Very 
often  in  the  same  subject  the  tactile  anaesthesia  is  still  frankly  ribbon 
form  while  the  thermo-analgesia  has  already  reached  the  segmeutarj^ 
period. 

9.  If  one  applies  or  maintains  during  a  certain  time  a  hot  or  cold 
body  upon  a  region  partly  deprived  of  sensibility,  it  is  frequently  the 
case  that  the  patient  complains  of  a  double  sensation ;  he  immediately 
recognizes  the  contact,  then  after  from  five  to  eight  seconds  he  per- 
ceives a  feeble  thermic  sensation.  This  curious  phenomenon  is  the 
consequence  of  a  law  that  the  more  a  sensibility  is  altered,  the  more 
slowly  the  sensation  is  produced.  The  number  of  seconds  which 
elapse  between  the  perception  of  contact  and  the  jjerception  of  tem- 
perature expresses,  so  to  speak,  in  figures,  the  degree  of  the  altera- 
tion of  the  thermic  sensibilit3^ 

10.  In  leprosy  the  sensitive  perversions  and  the  errors  of  localiza- 
tion are  not  rare. 

11.  The  anaesthesia  is  not  circumscribed  within  invariable  limits. 
It  embraces  two  zones :  one  fixed,  which  corresponds  to  the  regions 
first  and  the  most  profoundly  aft'ected  in  their  sensibility ;  the  other 
mobile,  at  the  level  of  which  the  sensibility  is  only  in  a  state  of  stupor 
and  not  extinct. 

MuscuLAE  Atrophy,  Tendinous  Eetractions,  and  Deformities. 

Atrophy  of  the  muscular  tissues  and  tendinous  retractions  give 
rise  to  various  deformities,  which  are  also  pathognomonic  features  of 
nerve  leprosy.  Leloir  says  that  muscular  atrophy  marches,  in  gen- 
eral, parallel  with  anaesthesia. 

Among  the  induced  changes  is  that  of  muscular  atrophy  accom- 
panied by  fibrillary  contractions  and  marked  diminution,  ending  in 
abolition,  of  the  electric  excitability. 

The  dynamometer  shows  marked  diminution  in  the  muscular  con- 


522  MOllKOVV — LEPROSY. 

tractility.  As  the  motor  fibres  are  destroyed,  proportionately  to  the 
muscular  atrophy  we  have  paresis  and  not  paralysis  as  a  resultant. 
Whether  this  is  due  to  a  lesion  of  the  trophic  fibres  of  the  nerve  or  to 
loss  of  function  by  motor  lesion  is  not  known.  In  any  case,  pure 
motor  i)aralysis  is  not  met  with  in  leprosy  unaccompanied  by  lesions 
of  the  sensory  and  trophic  systems.  The  muscular  atrophy  and  ten- 
dinous retractions  lead  to  conditions  and  deformations  identical  in 
appearance  with  those  resulting  from  idiopathic  nervous  <liseases. 

The  first  si^u  of  muscular  atrophy  is  usually  seen  in  the  upper 
liml)s.  Commencing  with  the  thenar  eminence  the  atrophy  involves 
the  other  muscles  of  the  hands,  particularly  the  interossei,  and  then 
extends  to  the  flexors  and  extensors  of  the  forearm  and  arm,  affecting 
particularly  the  extensors.  The  hands  become  (daw-shaped  from  the 
tendinous  contractions;  this  deformation  may  correspond  to  the 
Duchenne  type  of  paralysis.  The  hand  becomes  flattened,  the  mus- 
cular eminences  disajiyjear,  the  forced  extension  of  the  first  phalanges 
giving  a  concave  aspect  to  the  metacarpal  ])ortion ;  the  transverse  diam- 
eter of  the  hand  is  narrowed.  A  man's  hand  may  wither  t(^  the  size 
of  a  child's. 

The  little  finger  is  usually  the  first  to  become  flexed,  followed  by 
the  ring,  middle,  and  index  fingers,  the  thumb  being  usually  the  last. 
This  order  may  be  reversed;  sometimes,  l)ut  rarely,  the  thumb  is  the 
first  flexed.  In  the  production  of  the  "  leper  claw"  the  i)roximal  ])ha- 
langes  always  bend  backwards,  while  the  middle  and  distal  ])halanges 
are  curved  inwards  by  the  flexors..  The  first  phalanges  are  thus  in 
forced  extension,  the  others  in  forced  flexion.  There  may  be,  instead 
of  the  flexion  of  the  thumb,  a  horizontal  deviation  by  which  it  is 
curved  inwards.  The  degree  of  contraction  and  the  angle  at  which  the 
fingers  are  flexed  var^^  in  dift'erent  cases.  In  some  cases  only  one 
or  two  of  the  fingers  are  flexed;  in  other  cases  the  fingers  become 
twisted  on  their  axes  and  stand  out  at  the  most  grotesque  angles.  In 
advanced  cases  the  fingers  cannot  be  straightened  out  by  force.  This 
tendency  to  flexion  cannot  be  overcome  b^^  artificial  means.  Experi- 
ments have  been  made  in  straightening  out  the  fingers  and  binding 
them  on  a  flat  board,  nevertheless  the  process  still  continued. 

Tlie  following  case  illustrates  a  characteristic  deformation  of  the 
hand  from  tendinous  contractions: 

The  patient,  aged  20,  is  a  native  of  the  Sfindwich  Islands; 
father  and  mother  both  living  in  good  health ;  when  about  eight  years 
old  he  had  a  fall,  sustaining  a  fracture  of  the  right  clavicle.  For  a 
long  time  afterwards  he  experienced  a  sense  of  soreness  or  lameness  on 
the  affected  side.  Within  one  to  three  years  (the  patient's  testimony 
is  not  clear  uj^on  this  point)  he  noticed  a  numbness  of  the  hand,  with 


SYMPTOMS   OF   ANAESTHETIC   LEPROSY. 


52.^ 


a  tendency  to  contraction  of  the  fingers.  Tins  gradually  increased, 
becoming  more  pronounced.  He  was  treated  by  the  application  of 
the  actual  cautery  to  the  spine  on  the  supposition  that  his  trouble 
was  of  central  origin.  For  the  last  several  years  the  contraction  of 
the  fingers  has  remained  unchanged,  but  the  sensation  of  numbness 
has  crept  farther  uj?  the  forearm. 

Upon  examination,  he  was  found  to  be  well  nourished;  there  was 
some  atrophy  of  the  muscles  of  the  right  arm,  more  especially  below 
the  elbow ;  the  deltoid  was  somewhat  wasted ;  the  circumference  of 


i 

j 

1 
j 

r 

>* 

41 

J 

'  ft 

^■B^  <■, 

yi^      .4)*^^^ 

_:iflr7 

.^Kf'- 

1 

■ 

^*     ^--iaHMi^^'^fe.  1 

Fig.  9.— Characteristic    '  Leper  Claw." 


the  right  arm  was  one  inch  less  than  that  of  the  left ;  there  was  also 
atrophy  of  the  muscles  of  the  right  leg.  The  fingers  were  contracted, 
as  shown  in  Fig.  9;  over  the  knuckle  of  the  index  finger  a  superficial 
sore  from  slight  traumatism  had  existed  for  several  weeks  without 
healing;  the  nails  were  thickened  and  deformed. 

Over  the  lower  half  of  the  forearm  and  hand  was  entire  absence 
of  all  sensation;  from  the  middle  of  the  forearm  to  the  middle  of  the 
arm  there  was  impaired  sensation  over  regularly  limited  areas,  ex- 
tending higher  on  some  aspects  than  on  others ;  the  temperature  sense 
on  the  inner  side  of  the  arm  was  abnormal,  hot  water  being  mistaken 
for  cold,  etc.  On  the  right  lower  extremity  sensation  was  normal  ex- 
cept along  the  anterior  and  outer  surfaces  of  the  ankle  and  foot.  The 
anterior  leg  muscles  were  atrophied,  with  paresis. 

Electrical  excitability  of  the  muscles  of  the  arm  and  forearm  was 
obtainable,  but  below  this  point  was  lost.     Reaction  of  degeneration 


524  MORROW — LEPROSY. 

was  found  in  the  muscles  of  the  hand.  The  patellar  tendon  reflex  on 
the  right  side  was  exaggerated.  There  were  two  or  three  brownish 
spots  on  the  forearm,  of  the  duration  of  which  the  x>atient  could  give 
no  account. 

Quite  analogous  deformities  occur  in  the  muscles  of  the  lower 
extremities.  The  structures  affected  are  the  extensors  of  the  toes, 
which  are  the  flexors  of  the  ankle-joint,  and  as  a  result  the  ankle  can- 
not be  flexed,  and,  in  walking,  the  foot  is  raised  by  bending  and  lift- 
ing the  knee-joint  and  the  foot  is  carried  forwards  and  droi)ped  down 
e)i  masse,  or  the  point  of  the  foot  may  trail  downwards,  the  toes  first 
coming  in  contact  with  the  ground.  There  often  results  a  condition 
resembling  paralytic  clubfoot.  The  toes  may  be  flexed  en  grijiite, 
rendering  locomotion  uncertain  and  vacillating.  The  atrophy  may 
extend  to  the  muscles  of  the  thighs  aud  buttocks,  producing  a  condi- 
tion resembling  i^rogressive  muscular  atropln-. 

The  muscular  atrophy  is  characteristically  displayed  in  the  regions 
supplied  by  certain  cranial  nerves.  It  involves  the  trifacial  as  well 
as  the  facial,  and  the  resulting  deformities  may  resemble  other  facial 
paralyses  of  peripheral  origin.  The  i:)aralysis  may  aft'ect  the  facial 
muscles,  drawing  the  face  to  one  side  and  constituting  a  character- 
istic deformity.  Paralysis  of  the  motor  muscles  of  the  eyes  often  gives 
a  staring  expression  to  the  face,  altering  the  entire  physiognom}-. 
The  parah'sis  of  the  infraorbital  branch  causes  atrophy  of  the  lower 
lid  and  paralysis  of  the  orbicularis.  The  upper  lid  overhangs  the 
lower  lid,  which  is  everted,  and  the  tears  flow  down  the  face,  diverted 
by  the  deformity  of  the  lid  from  their  natural  channel.  The  patient  is 
unable  to  close  the  eye,  and  in  the  effort  to  do  so  continually  contorts 
the  face.     The  eyeballs  roll  upwards,  while  the  lids  remain  stationary.* 

When  the  fifth  nerve  is  affected,  the  lacrymal  glands  become 
atrophied  and  disappear,  and  the  secretion  of  tears  is  stoi)ped.  The 
eyelashes  also  fall  out.  The  eyeball  being  insufficiently  protected  by 
its  natural  secretion  becomes  dry  and  inflamed,  the  cornea  opaque, 
and  the  eye  may  be  lost  through  ulceration  of  the  cornea.  The  eyes 
are  also  liable  to  be  injured  by  exposure  to  bright  light,  dust,  and 
other  irritants  from  loss  of  protection  of  the  eyelashes.  The  loss  of 
sensation  may  be  so  complete  as  to  permit  of  operations  for  cataract 
or  other  affections  of  the  eye  without  the  use  of  an  anaesthetic. 

The  buccal  branches  of  the  trifacial  mav  also  be  affected,  with 


*  In  the  pest  liouse  in  San  Francisco  I  observed  three  lepers,  all  brothers,  in 
whom  this  particular  form  of  paralysis  was  so  marked  that  it  was  impossible  for 
them  to  close  the  eyes  voluntarily.  At  night  the  eyelids  w^ere  strapped  together 
with  adhesive  plaster. 


SYMPTOMS  OF  ANESTHETIC  LEPROSY.  525 

paralysis  of  the  buccinator  muscles.  The  cheeks  and  lips  are  flaccid 
and  pendulous.  In  severe  cases  the  lips  puff  out,  as  in  facial  paraly- 
sis. In  many  cases  one  of  the  first  signs  of  leprous  involvement  of 
this  nerve  is  inability  on  the  part  of  the  patient  to  whistle,  and  pro- 
nunciation of  labials  is  difficult.  The  paralysis  of  the  lower  lip 
causes  the  lip  to  hang  down,  displaying  the  teeth  and  gums,  and 
there  is  a  more  or  less  continuous  flow  of  saliva  from  the  mouth. 

The  Mucous  Membranes. 

The  trophic  changes  are  not  confined  to  the  skin  and  muscles  of 
the  face,  but  affect  also  the  mucous  membranes  of  this  region.  The 
oculopalpebral  membranes  are  subject  to  constant  irritation  from  ex- 
posure to  various  external  irritants.  Owing  to  the  lack  of  the  normal 
lubricating  secretion,  the  conjunctiva  becomes  dry  and  inflamed. 
Photophobia  is  often  present  in  a  marked  degree.  What  has  been 
termed  a  condition  of  "  cutisation"  of  the  conjunctival  mucous  mem- 
brane takes  place,  similar  to  what  is  described  in  connection  with 
changes  in  the  mucosa  of  the  air  passages.  Phlyctenular  lesions  with 
resulting  ulcerations  and  opacities  of  the  cornea  are  apt  to  occur. 
These  ulcerations  are  as  a  rule  superficial  and  are  not  apt  to  perforate 
the  cornea  and  puncture  the  anterior  chamber. 

Similar  trophic  changes  occur  in  the  mucous  membranes  of  the 
upper  air  passages,  being  probably  due  to  degenerative  changes  in  the 
branches  of  the  trifacial.  The  mucous  membrane  of  the  nasal  fossse, 
which  in  the  early  stage  is  the  seat  of  irritation  and  hypersecretion, 
becomes  dry,  red,  and  inflamed  and  later  the  seat  of  ulcerative 
changes.  The  ulcerations,  at  first  superficial,  become  covered  with 
crusts  which  partially  close  the  passages,  interfere  with  respiration, 
and  modify  the  character  of  the  voice.  Upon  detaching  or  blowing 
out  the  crusts,  they  are  found  to  be  blood-stained  upon  their  attached 
surface,  and  epistaxis,  more  or  less  profuse,  frequently  follows.  The 
ulcerations  upon  the  septum  not  infrequently  lead  to  perforation  and 
sometimes  complete  destruction  of  the  support  of  the  nose,  which 
consequently  becomes  flattened  out. 

One  of  the  characteristic  mucous-membrane  symptoms  consists  of 
complete  loss  of  sensibility  about  the  soft  palate,  uvula,  and  back  of 
the  pharynx,  not  amounting  to  paralysis,  but  seriously  interfering 
with  the  proper  function  of  the  muscles  of  the  throat  which  are  affected 
by  it.  There  may  be  regurgitation  through  the  nostrils,  causing 
much  difficulty  in  swallowing.  The  anaesthesia  is  so  marked  that 
the  patients  do  not  wince  when  a  sharp  instrument  is  plunged  deeply 
into  the  parts  mentioned. 


026 


MORROW — LEPROSY. 


Stage  of  Mutilations. 
JJniilatio))^  of  the  Ski/i,  l>(>}ns.  <i/nl  ^irt'irnhitiim.'i. 

In  many  cases  tlie  mnscular  atrophies  aud  coutractnres  mark  the 
end  or  culmination  of  the  deforming  process.     In  other  cases,  when 

there  is  a  complete  disorgani- 
ication  of  the  trophic  nerves, 
profound  nutritional  changes, 
with  destruction  of  the  l)ones 
and  nnitilatious  of  the  ex- 
tremities, follow, 

III  the  milder  class  of 
cases  the  trophic  disorder  is 
I  expressed  in  superficial  ul- 
J  cerations  due  to  the  dimin- 
I  ished  vitality  of  the  skin  from 
i  changes  in  its  structure  and 
=  the  loss  of  resisting-power 
=  conferred  hy  a  normal  nerve 
£       supply.       Owing   to  the    de- 

1  structiou  of  the  sebaceous 
i  and  sweat  glands  and  the 
^  suppression  of  the  sweat  and 
&      oily  exudations  the  skin  loses 

2  its  soft,  sui)ple  feel  and  be- 
i  comes  dry,  harsh,  and  parcli- 
I  ment-like;  the  epidermis 
I  cracks  easily  and  loses  its 
^  protective  jiower  of  shielding 
I  the  underlying  tissues.  It 
^f  has  become  more  vulnerable 
^  to  slight  causes  of  injury. 
^  These  nutritional  changes 

are  at  first  confined  to  the 
anesthetic  patches,  but  later 
become  manifest  over  the 
general  surface  of  the  extrem- 
ities.      On    accouut    of    the 

anaesthesia    wounds,     barns.. 

and  various  traumatisms  oc- 
cur without  the  patient's  knowledge,  followed  hx  superficial  ulcera- 
tions wliicli  aro  long   in  healing.      Even  at  an   early  stage    of    the 


SYMPTOMS   OF  ANESTHETIC   LEPROSY.  527 

disease  tlie  Lands  aud  feet  may  be  covered  with  wouuds  aud  scars 
froiQ  ■various  causes.  Tlie  slightest  injury  may  cause  disorganiza- 
tion of  the  tissues.  The  chafing  of  the  shoe,  for  example,  may  cause 
a  blister  with  siiperficial  ulceration  which  may  re(iuire  mouths  for 
its  healing.  Often  the  skin  over  the  joints  of  the  hands  or  fingers, 
which  are  at  first  more  prominent  from  atrophj^  of  the  overlying 
tissues,  becomes  thinned,  cracked,  aud  fissured,  producing  dry,  deep 
rhagades,  which  may  ulcerate  and  show  no  tendency  to  heal.  A 
breach  of  continuity  may  occur  in  the  skin  over  the  osseous  promi- 
nences of  the  semiflexed  phalanges,  the  thumb,  wrist,  elbow,  knee, 
metatarsal  or  phalangeal  articulations. 

The  more  profound  trophic  changes  which  occasion  the  character- 
istic mutilations  of  this  form  may  be  consecutive  to  caries  and  ulcer- 
ations of  the  bone,  or  they  may  take  place  hj  a  process  of  interstitial 
absorption  or  what  may  be  termed  spontaneous  resorption  without 
intervention  of  the  ulcerative  process.  In  other  cases  the  deep  ulcera- 
tions may  begin  in  the  pemphigus  blebs  located  on  the  phalangeal 
articulations,  uncovering  the  deeper  tissues,  the  consecutive  disease 
of  which  leads  to  the  elimination  of  bone  and  the  extensive  mutila- 
tions which  characterize  this  j)eriod  of  leprosy. 

The  indolent  anaesthetic  ulceration  which  starts  in  the  fissures  of 
the  skin,  instead  of  remaining  sui^erficial,  may  become  more  profound 
and  destructive.  Not  infreciuently  the  parts  anterior  to  the  fissure 
become  gangrenous,  resulting  in  their  spontaneous  amputation.  The 
reparative  process  is  usually  prompt  and  complete,  the  stump  healing 
perfectly.  At  other  times  the  ulcerative  process  gains  in  depth,  de- 
stroying the  cellular  tissue,  denuding  the  extremities  to  the  bones, 
penetrating  the  articulations,  and  leading  to  loss  of  the  bones.  These 
ulcers,  with  callous  borders  formed  by  the  muscular  wall,  are  often 
atonic  and  may  persist  for  months  without  healing. 

In  another  class  of  cases  the  first  sign  of  beginning  necrosis  of  the 
bones  is  manifest  in  the  swollen,  tense  condition  of  the  overlying  tis- 
sues and  is  often  attended  with  fever  and  constitutional  reaction. 
This  swelling  becomes  softer,  suppurates,  and  makes  its  way  to  the 
surface,  which  opens  and  gives  exit  to  a  collection  of  sanguineous  pus, 
and  there  will  be  found  a  sinus  leading  down  to  the  necrosed  bone. 
This  is  gradually  broken  down  and  extruded  by  the  suppurative 
process,  when  the  sinus  heals.  In  the  case  illustrated  in  Fig.  11 
the  entire  hand  was  necrosed  and  gradually  detached  from  the  body ; 
in  the  same  way  an  entire  foot  may  be  amputated. 

The  following  cases  which  came  under  the  observation  of  Dr.  Mc- 
Dougal,  of  New  Lexington,  Ohio,  and  were  reported  by  him  in  1895, 
are   of  exceeding  interest   on  account  of  their   mysterious  origin. 


528 


MORROW — LEPROSY. 


That  they  are  examples  of  leprosy  there  can  be  but  little  doubt,  al- 
though the  source  of  the  infection  cannot  be  definitely  traced.  Pos- 
sibly the  father  may  have  contracted  the  disease  in  the  South  during 
his  militarv  service  and  communicated  it  to  his  daughters.     The  cases 


Fig.  n.— Spontaneous  Amputation  of  the  Hand  in  Anaesthetic  Leprosy. 

are  also  of  interest  in  connection  with  the  differential  diagnosis  of 
leprosy  and  syringomyelia.  They  were  diagnosticated  by  a  number 
of  dermatologists  as  syringomyelia  of  the  Morvan  type. 

"  Hannah  M.  Garey,  18  years  old,  first  came  under  my  observation 
in  December,  189-4,  She  presented  the  following  manifestations  of 
a  disease  we  diagnosed  as  anaesthetic  leprosy :  Tlie  left  hand  and 
lower  forearm  were  swollen  and  rather  firmly  thickened,  the  hand 
and  wrist  being  about  twice  the  normal  size.  The  distal  phalanges 
were  all  lost,  except  from  the  little  finger  and  thumb,  and  the  stumps 


SYMPTOMS   OF   AN-SJSTHETIO  LEPROSY.  529 

were  all  healed.  The  thumb  nail  was  deformed  and  discolored.  The 
hand  was  being  amputated  at  the  radiocarpal  articulation  by  a  nar- 
row, encircling  ulcerative  process,  and  the  work  was  so  near  comple- 
tion that  only  the  ulnar  vessels  and  some  of  the  tendons  remained. 
Both  surfaces  were  covered  by  granulations,  were  bathed  with  ex- 
tremely foul-smelling  pus,  and  were  yet  held  in  close  apposition, 
except  at  the  bordering  skin,  where  some  retraction  had  taken  place 
in  the  healing  process  which  had  begun. 

"  The  right  hand  and  fingers  were  somewhat  swollen  and  clubbed, 
and  all  the  distal  phalanges,  except  those  of  the  little  finger  and 
thumb,  were  lost.  The  wrist-joint  was  somewhat  deformed  because 
of  an  unnatural  prominence  of  the  head  of  the  ulna  on  the  dorsal  side. 
Both  feet  were  swollen  and  thickened,  and  this  condition  also  in- 
volved to  some  extent  the  legs,  being  more  marked  in  the  left.  From 
the  left  foot  the  first  and  second  toes  were  entirely  lost,  the  third 
toe  was  off  at  the  proximal  phalangeal  joint,  and  the  fifth  toe  was  all 
lost.  On  the  plantar  surface  of  the  stump  of  the  great  toe  was  a  thick, 
dark  crust  covering  an  unhealed  ulcer.  In  the  middle  of  the  left  sole 
was  an  ulcer,  the  size  of  a  silver  half-dollar,  which  reached  deep  into 
the  foot  and  from  which  there  came  a  very  offensive  discharge.  From 
the  right  foot  the  great  toe  was  lost,  the  second  and  third  were  off  at 
middle  of  proximal  phalanx,  and  the  fourth  was  pointed  upwards  so 
that  it  was  considerably  out  of  line  with  the  others.  The  little  toe 
was  not  affected,  except  that  it  was  involved  in  the  general  thickening 
of  the  foot.  All  the  affected  members  were  more  or  less  anaesthetic, 
the  thermal  anaesthesia  being  especially  marked. 

"  There  was  a  blister  the  size  of  a  silver  quarter  on  the  back  of 
right  arm  just  above  the  olecranon.  The  end  of  the  tongue  had  been 
destroyed  by  ulcerations  that  had  healed,  the  left  side  of  the  lower  lip 
and  both  wings  of  the  nose  had  suffered  loss  from  the  same  cause  and 
were  consequently  deformed,  and  the  lower  jaw  had  likewise  suffered 
loss  of  bone,  teeth,  and  gum.  The  girl's  eyes  looked  weak  and  blink- 
ing, and  her  vision  was  poor. 

"  This  malady  began  to  manifest  itself,  so  the  mother  states,  by  ab- 
scess formations  in  the  legs  when  the  patient  was  about  fifteen  months 
old.  In  two  or  three  years  the  toes  began  to  ulcerate  and  come  off, 
and  then  the  hands  became  involved.  The  flesh  ulcerated  from  the 
fingers,  leaving  the  blackened,  dry  bones  exposed,  and  these  she  per- 
sistently drummed  on  the  tables  and  chairs  until  her  mother  cut  them 
off  with  shears. 

"  She  menstruated,  though  irregularly,  after  she  was  fourteen 
years  of  age  until  about  one  year  ago,  when  the  menses  ceased. 

"  January  18th,  1895, 1  saw  her  again.  At  that  time  she  was  sweat- 
ing freely,  though  the  house  was  cold,  and  her  pulse  was  accelerated. 
She  complained  of  pain  in  the  neck  and  left  leg,  from  which  she  had 
been  suffering  much.  Her  mother  said  she  had  lately  fallen  several 
times,  limp  and  motionless,  and  that  she  had  been  having  some  sort  of 
choking  spells.  The  hand  was  still  further  separated,  so  that  it  hung 
downwards  when  the  arm  was  raised.  On  the  back  of  the  hand  was 
an  extensive  gangrenous  blister,  due  to  the  pressure  of  splints  used  to 
hold  the  hand  in  position.  The  epidermis  covering  the  remainder  of 
Vol.  XVIII.— 34 


530  MOKEOW — LEPROSY. 

the  hand  had  been  recently  shed  and  replaced  by  the  formation  of 
new.  The  blister  on  the  elbow  had  healed  and  the  skin  marking  its 
location  was  papery  and  harsh,  and  completely  insentient  to  touch  or 
pain.  The  plantar  ulcer  was  healing  and  covered  by  a  thick,  black, 
offensive  crust. 

"  February  15th  I  next  saw  her.  At  this  time  there  was  a  large 
ulcer,  with  sharplj-  defined  edge,  on  the  back  of  the  hand,  correspond- 
ing in  size  and  location  to  the  blister  seen  on  a  former  visit.  Since 
my  previous  visit  there  had  appeared  for  the  first  time  in  the  history 
of  the  case — so  far  as  I  was  able  to  learn — an  eruption  on  the  left  side 
of  the  neck  and  on  the  front  of  the  left  leg.  The  eruptive  spots  were 
not  raised,  were  dark  j'ellowish-browu  in  color  on  the  leg  and  darker 
on  the  neck.  They  were  thickly  set,  and  made  with  the  surrounding 
skin  a  dappled  appearance,  which  shows  fairly  well  on  the  leg  in  the 
I^hotograph.  Since  the  appearance  of  the  erui)tion  there  have  been 
no  choking  or  fainting  spells.  The  plantar  ulcer,  after  a  duration  of 
about  five  j^ears,  was  now  healed.  At  this  time  the  negatives  were 
obtained  from  which  the  photograph  was  made  (Fig.  11)  and  the 
hand  was  removed  and  sent  away  for  bacteriological  examination. 

"  Sections  from  this  specimen  were  stained  for  lepra  bacilli  with 
negative  results.  The  sections  containing  giant  cells  were  also  stained 
for  tubercle  bacilli  ;  none  were  found. 

"  Her  younger  sister  Hattie,  eight  years  of  age,  has  been  afflicted 
for  about  three  years.  Her  feet  are  clubbed  and  legs  stocky.  The 
great  toe  of  the  left  foot  is  off  at  the  middle  of  the  proximal  phalanx. 
There  is  a  dark  crust  on  the  lower  part  of  the  stump.  The  distal  phalanx 
of  the  second  toe  is  lost.  The  right  great  toe  is  like  the  left.  The  nail 
is  lost  from  the  second  toe,  and  the  ulcer  which  was  present  on  the  top  of 
this  toe  is  now  healed.  The  little  toe  has  been  entirely  destroyed  and 
a  healthy  stump  remains.  There  is  some  anaesthesia  of  the  feet  and 
legs.  There  was  a  moderately  indurated  swelling  on  the  outer  front 
side  of  the  leg  just  above  the  ankle,  which  has  almost  disappeared. 

"  The  hands  are  also  affected.  They  are  thickened  and  chubby. 
The  thumb  nails  show  evidence  of  disease.  The  ends  of  the  index-fin- 
gers are  off,  and  here  an  apology  for  nails  is  offered  in  the  existence 
of  small,  dark,  horn}'  thickenings  on  the  centres  of  the  ends  of  the  fin- 
gers. On  the  radial  side  of  the  wrist  the  skin  is  rough,  and  here  are  a 
number  of  small  wart-like  elevations.  There  are  a  number  of  blisters 
on  the  palmar  surfaces  of  the  hands.  These  are  accounted  for  by 
the  fact  that  she  is  fond  of  parching  corn  in  a  skillet  on  the  stove,  and 
her  touch  cannot  appreciate  a  destructive  degree  of  heat ;  consequently 
her  hands  are  frequently  burned.  She  is  unable  to  appreciate  any 
difference  between  the  feel  of  a  bottle  filled  with  hot  and  another  filled 
with  cold  water.  Her  eyes  are  red  and  tearful.  Her  voice  is  coarse 
and  croaks,  and  she  has  a  croupy  cough  at  night. 

"  Both  have  suffered  at  times  from  painful  nerves,  and  when  deep 
abscesses  formed,  or  when  amputations  began  in  the  bones,  they  suf- 
fered from  them.  But  the  ulcerations,  though  reaching  deep  into  the 
tissues  or  even  destroj'ing  a  member,  have  not  been  painful. 

"  Hannah  walked  with  little  discomfort  on  the  plantar  ulcer,  and 
during  the  later  stages  of  the  destructiye  process  that  robbed  her  of 
her  hand  she  suffered  none,  and  laughed  when  it  was  being  cut  away. 


SYMPTOMS    OF   ANESTHETIC   LEPROSY. 


531 


"  The  motlier  insists  that  tlie  ulcerations  are  always  tlie  result  of 
some  accidental  injury.  They  sometimes  heal  kindly  after  a  variable 
duration,  and  sometimes  go  on  to  complete  destruction  of  the  part." 

In  a  recent  communication  (May  12th,  1899)  Dr.  McDougall  states : 
"  Hannah  continued  losing  remnants  of  her  fingers  and  toes  and  hav- 
ing plantar  ulcers  until  she  died  from  pneumonia  this  spring.  The 
living  girl  has  suffered  some  further  mutilation  of  the  feet  since  I  last 
saw  her.  The  first,  second,  and  fifth  toes  are  now  gone  from  the  left 
foot.  There  is  also  a  deep  ulcer  in  the  plantar  surface  at  the  middle 
of  the  heel.  It  is  indolent,  dark,  and  deep,  and  rather  dry  so  one  can 
see  into  it.  It  would  admit  a 
lead  pencil  nearly  an  inch.  The 
mother  says  it  came  a  number 
of  weeks  ago  from  stepping  on 
a  nail.  The  foot  is  also  swol- 
len and  inflamed  from  the  for- 
mation of  an  abscess  which  has 
opened  through  a  round  hole 
in  the  top  of  the  foot  an  inch 
from  the  base  of  the  second 
toe.  The  discharge  is  thin, 
purulent,  and  offensive.  Not- 
withstanding the  condition  of 
the  foot  she  walks  and  runs 
with  no  sign  of  pain  except  a 
moderate  limp.  The  mother 
says  the  gathering  was  caused 
by  the  '  mare  '  stepping  on  the 
foot.  Thermal  anaesthesia 
seems  complete  about  the  external  malleoli  and  for  a  little  way  above. 
We  filled  a  two-ounce  bottle  with  hot  water  and  one  with  cold,  and 
grasping  them  with  her  hands,  she  could  not  distinguish  them. 
There  is  quite  marked  thickening  of  the  left  ulnar  nerve." 

These  sisters  have  never  been  outside  the  State  of  Ohio.  Both 
parents  and  all  the  grandparents  were  natives  of  Ohio,  and  belonged 
to  healthy,  long-lived  families.  The  parents  were  married  in  1866. 
There  are  eight  children,  and  all  are  healthy  except  Hannah,  the 
fourth  born,  and  Hattie,  the  last  born.  The  mother  is  forty-four 
years  old  and  healthy.  The  father,  who  was  a  soldier  during  the 
War  of  the  Rebellion,  is  reported  as  having  died  of  some  brain  trou- 
ble March  10th,  1893.  He  had  an  offensive  discharge  from  the  nose  and 
an  eruption  on  the  upper  lip  and  the  end  of  the  nose.  This  trouble 
developed  shortly  after  marriage,  and  was  never  recovered  from. 
The  regiment  of  which  he  was  a  member  was  stationed,  during  the 
few  months  it  was  in  service,  at  Nashville,  Tenn.,  and  at  Dalton, 
Kingston,  and  Macon,  Ga. 


Fig.  12, 


-Spontaneous  Amputation   of  the  Toes 
Anaesthetic  Leprosy. 


Perforating  Ulcer.— Tlho,  plantar  ulcer  which  is  so  common  and 
characteristic  a  symptom  of  this  form  of  leprosy  is  only  a  deep-seated 
necrosis  due  to  trophic  disorders,  the  starting-point  of  which  may  be 
an  injury  of  the  integument.     It  occurs  most  frequently  among  lepers 


532  MORROvr — leprosy. 

who  go  barefoot,  and  is  often  due  to  a  stone  bruise  or  other  injury.  It 
usually  begins  as  a  circumscribed  callosity  which  appears  over  the 
sole  of  the  foot  or  palm  of  the  hand  or  upon  any  portion  of  the  meta- 
tarsus or  metacarpus.  It  rarely  affects  the  phalanges  or  bones  which 
are  easily  detached,  but  more  often  bones  which  are  firmly  impacted 
and  cannot  readily  be  dislodged.  The  epidermal  thickening  is  usu- 
alh'  uplifted  in  the  form  of  a  bleb  or  blister  and  gradually  breaks  and 
becomes  ulcerated.  The  ulcer  increases  in  depth  until  it  finall}* 
reaches  the  bones,  which  it  slowly  disintegrates  and  destroys.  These 
ulcers  are  essentially  atonic  and  may  persist  for  months  and  years 
with  but  little  change.  It  has  been  found  that  if  a  necrosed  bone  is 
cut  down  upon  and  removed  the  ulcer  heals.     These  perforating  ulcers 


Fig.  13.— Plantar  Ulcer. 

lead  to  various  mutilations  and  often  necessitate  the  amputation  of 
the  member.  In  other  cases  the  lesion  can  scarcely  be  described  as 
an  ulcer,  but  rather  as  a  sinus  leading  from  an  aperture  in  the  centre 
of  the  callosity  down  to  the  necrosed  bone.  The  walls  of  the  sinus 
are  lined  with  fungoid  granulations,  which  may  be  found  protrading 
from  the  opening.  Around  the  granulations  is  found  a  flattened  area 
of  whitish-yellow,  thickened  epidermis. 

Spontaneous  Resorption  of  Bones. — In  another  class  of  cases  the 
disappearance  of  the  bones  is  a  phenomenon  of  absorption.  It  has 
been  described  as  a  species  of  rarefying  ostitis,  giving  rise  to  what 
may  be  fitly  termed  leprous  osteomalacia  (Leloir).  It  is  more  apt  to 
affect  the  contracted  fingers  in  cases  of  main  en  grife.  The  phalanges, 
or  the  bones  of  the  metacarpus  and  metatarsus,  gradual!}-  atrophy  and 
melt  away  until  only  the  fibrous  tissue  which  formerly  enclosed  them 
remains.  This  also  shrivels  up  and  becomes  mummified  until  the  fin- 
gers maj'  be  no  thicker  than  a  pencil.  The  process  usualh'  first  at- 
tacks the  second  phalanx.  One  phalanx  after  another  may  be  removed 
in  the  manner  described  until  the  i>halanges  of  the  fingers  and  toes 


SYMPTOMS   OF   ANESTHETIC   LEPEOSY.  533 

are  all  destroyed.  It  may  affect  one  phalanx  and  respect  the  others. 
Thus  the  second  phalanx  may  be  destroyed,  leaving  the  first  and  third 
intact;  or  the  second  or  third  may  be  destroyed,  and  the  first  may 
rest  upon  the  metacarpus. 

The  nail  seems  to  be  endowed  with  a  remarkable  power  of  resist- 
ance. As  one  bone  after  another  is  destroyed  the  fingers  shrink  and 
shriyel  up  until  nothing  may  be  found  except  the  nail  occupying  the 
metacarpal  or  metatarsal  bone  corresponding  to  the  phalanx.  In 
rare  cases  the  terminal  portion  of  the  phalanx  may  be  encircled  by  a 
fissure  which  gradually  deepens  until  the  constricted  portion  in  front 
becomes  swollen  to  twice  or  three  times  its  normal  size  and  is  attached 
only  by  a  narrow  pedicle  suggesting  a  similitude  to  certain  cases  of 
ainhum.  Although  the  nails  are  seen  to  be  endowed  with  a  wonder- 
ful resistance  even  at  an  advanced  stage  of  the  disease,  they  may  suf- 
fer in  their  nutrition.  The  dystrophic  changes  are  seen  in  thinning 
of  the  nail  and  more  or  less  complete  exfoliation,  with  degeneration 
of  the  matrix.  In  some  cases  the  end  of  the  finger  is  seen  capped 
with  a  slight  rudimentary  vestige  of  a  nail. 

The  mutilations  of  leprosy  which  represent  the  profoundest  grade 
of  leprous  destruction  may  in  some  cases  coexist  with  a  condition  of 
comparative  health.  The  patient  may  live  for  many  years  in  this 
stunted  and  maimed  condition,  although  practically  helpless.  Ordi- 
narily in  the  advanced  stage  of  the  disease  there  develop  certain  con- 
stitutional disorders.  Morbid  stomachal  conditions  lead  to  emacia- 
tion and  the  general  health  gradually  fails,  with  a  tendency  to  visceral 
complications. 

Patients  complain  of  sensations  of  chilliness  and  cold.  This  form 
of  subjective  sensations  constitutes  one  of  the  most  constant  and  dis- 
tressing symptoms.  Patients  hug  the  stove  or  fire  in  their  ineffectual 
efforts  to  keep  warm,  and  to  this  is  often  due  the  frequent  occurrence 
of  burns  among  lepers.* 

Hillis,  as  well  as  Daniellsen  and  Boeck,  have  observed  that  the 
body  temperature  is  several  degrees  below  normal  in  the  advanced 
stages  of  the  disease.  Coincident  with  the  subnormal  temperature 
the  action  of  the  heart  is  enfeebled,  and  there  is  diminution  in  the 
frequency  of  the  pulse. 

Sexual  Functions. — The  inhibitory  effect  upon  sexual  desire  and 
capacity  is  less  marked  in  nerve  leprosy  than  in  the  tubercular  form. 
In  many  cases  it  would  appear  that  this  function  is  at  first  stimulated 
and  the  extinguishment  of  sexual  desire  and  capacity  takes  place 

*  A  similar  phenomenon  is  observed  in  morphoea  of  generalized  distribution. 
In  such  a  case  under  my  observation  the  patient  would  sit  for  hours  in  the  sun  en- 
veloped in  a  blanket  or  close  to  a  fire  in  a  vain  endeavor  to  keep  warm. 


534  MOEEOW — LEPROSY. 

more  gradually  and  at  a  more  advanced  stage  o^  the  disease.  I  may 
quote  from  a  letter  of  Mr.  Dutton,  wlio  lias  charge  of  the  Home  for 
Leper  Boys  in  Molokai,  as  to  the  effect  of  the  two  forms  of  disease  upon 
sexual  functions.  "  Notwithstanding  the  old  belief  that  in  the  tuber- 
cular form  this  function  assumed  unusual  excitability^  it  has  always 
seemed  to  me  that  this  condition  lay  with  anaesthetic  cases,  or  with 
the  mixed  cases.  Of  home  inmates  who  leave  the  home  to  live  with 
women,  I  should  say  that  they  are  generally  those  who  have  marked 
anaesthetic  features."  This  result  is  precisely  what  would  be  inferred 
from  the  implication  of  the  testicles  by  the  bacilli  in  the  tubercular 
form,  and  the  comparative  exemj)tion  of  these  organs  in  the  anaes- 
thetic form.  It  has  been  demonstrated  by  Babes  and  others  that  the 
bacilli  are  found  in  great  abundance  and  are  localized  in  the  connec- 
tive tissues  and  seminiferous  tubules  in  the  tubercular  form. 

The  procreative  capacity  of  lepers  is  not  so  much  impaired  as  is 
commonly  believed.  The  statistics  of  the  leper  settlement  of  Cape 
Town,  and  of  the  Norwegian  lepers  who  have  emigrated  to  this  coun- 
try, to  which  reference  is  elsewhere  made,  show  that  lepers  may  be 
quite  prolific. 

Menstruation. — In  most  cases,  especially  if  the  disease  has  existed 
for  some  time,  the  menses  become  irregular,  and  in  exceptional  cases 
they  cease  completely  long  before  the  normal  period  of  the  meno- 
pause. When  leprosy  develops  in  childhood  or  before  puberty  the 
menses  rarely  appear  at  all.  The  disease  has  an  inhibitory  effect  on 
this  function,  as  well  as  a  stunting  effect  upon  the  growth,  arresting 
the  development  of  the  normal  bodily  functions.  The  aspect  of  pre- 
cocious senility,  the  nervous  trouble  culminating  in  contractures,  ul- 
cerations, and  consecutive  mutilations  with  progressive  emaciation, 
form  an  easily  recognized  picture  of  leprosy  in  childhood. 

Termination. 

The  lamentable  aspect  presented  by  trophoneurotic  lepers  at  an 
advanced  stage  of  the  disease  has  been  thus  graphically  described  by 
Leloir : 

"The  anaesthesia  may  occupy  the  entire  body.  In  any  case  it 
has  invaded  the  upper  and  lower  limbs  completelj^  the  face,  etc. 
The  facial  mask  is  immobilized  by  paralysis  and  muscular  atrophy, 
and  in  this  yellowish,  waxy,  cadaveric,  emaciated  and  deformed  im- 
mobile mask  one  sees  two  large  eyes,  open,  fixed,  but  white,  dull, 
without  light,  for  the  unfortunate  is  blind.  Saliva  constantly  flows 
from  the  corners  of  the  paralyzed  mouth.  The  nose  is  sometimes 
deformed ;  the  sfense  of  smell  has  disappeared  partially  or  altogether, 
likewise  the  taste ;  the  hairs  of  the  face  have  fallen. 


TEEMTNATION  OF  AlJiESTHETIC  LEPEOSY.  535 

"  Tlie  hands  and  feet  are  liorriblv  deformed  and  mutilated,  and 
have  no  longer  a  human  appearance.  The  muscles  of  the  limbs  are 
atrophied.  Ulcerations,  more  or  less  vast,  have  denuded  the  bones 
of  the  limbs  and  secrete  an  indescribable  humor.  The  patient  exhales 
a  sweet,  unsavorr  odor  analogous  to  that  of  the  warm  cadaver.  He 
is  in  a  state  of  profound  depression ;  deprived  of  appetite,  tormented 
by  insatiable  thirst,  sometimes  again  by  frightful  neuralgic  pains ; 
he  remains  lying  or  sitting  entire  days,  without  occupying  himself 
with  that  which  is  passing  around  him.  One  is  obliged  to  feed  him, 
put  him  to  bed,  carry  him.  He  appears  plunged  in  a  profound  stu- 
por and  witnesses  indifferently  the  progressive  mutilation  of  his  body. 
Neverthless,  if  one  interrogates  him,  one  perceives  that  his  intelli- 
gence is  rather  dulled  than  lost." 

Patients  die  of  marasmus  or  exhaustion  consequent  upon  long- 
continued  digestive  disorders,  colliquative  diarrhoea,  of  amyloid  de- 
generation of  the  kidneys  and  internal  organs,  or  of  some  inter- 
current disease.  They  rarelj-  die  of  tuberculous  complications. 
Such  complications  are  as  uncommon  in  this  form  of  leprosy  as  is 
amyloid  degeneration  in  the  tubercular  form. 

The  average  duration  of  life  in  the  anaesthetic  form  is  said,  by 
Daniellsen  and  Boeck,  to  be  from  eighteen  to  twenty  years.  In  some 
cases  this  period  is  prolonged  to  twenty,  thirty,  or  forty  years  or 
longer.  The  transition  of  the  anaesthetic  into  the  tubercular  form 
will  be  considered  in  connection  with  the  mixed  type  of  leprosy. 

Instead  of  proceeding  to  this  fatal  termination,  anaesthetic  leprosy, 
after  attaining  a  certain  degree  of  development,  may  be  apparently 
arrested.  All  the  symptoms  abate,  the  spots  gradually  clear  up,  the 
bullae  cease  to  appear,  even  the  sensibility  of  the  skin,  which  was  in 
abeyance  for  a  long  time,  becomes  reestablished.  While  the  pa- 
tient may  show  in  his  atrophied  and  paralyzed  muscles,  his  maimed 
and  mutilated  limbs,  the  vestiges  of  the  disease  which  has  occasioned 
them,  there  is  no  evidence  that  the  bacilli  are  present  or  likely  to  be 
awakened  into  activity.  The  patient  may  live  to  quite  an  advanced 
age,  and  finally  die  of  intercurrent  disease. 

This  arrest  may  take  place  at  any  time  during  the  course  of  the 
disease,  and  it  is  a  question  of  great  practical  importance  whether  such 
cases  can  be  considered  cured.  Impey  says  that  in  every  leper  es- 
tablishment there  may  be  found  cases  of  cured  leprosy.  In  his  opin- 
ion these  stigmata  of  the  disease  have  the  same  significance  as  the 
scars  of  syphilis,  and  as  a  practical  outcome  of  this  belief  he  insists 
that  it  is  wrong  to  confine  such  cured  cases  in  close  association  with 
tubercular  lepers  as  they  are  liable  to  be  reinfected.  A  number  of 
cases  are  instanced  in  which  he  thinks  reinfection  has  taken  place, 


536  MORROW— LEPEOSY. 

the  patient  again  exhibiting  the  early  and  late  phenomena  of  the  dis- 
ease precisely  as  if  he  had  never  had  it.  To  this  Ashmead  replies : 
"How  can  immune  tissue  be  inoculated?  Certainly  the  anaesthetic 
leper  would  be  more  liable  to  be  contaminated  in  his  healthy  parts 
by  autoinfection  than  by  other  lepers.  If  the  cutaneous  tissues  of 
the  anaesthetic  leper  are  immune,  how  can  they  be  inoculated  at  all?" 
To  this  it  may  be  replied  that  it  is  quite  possible  that  the  few  bacilli 
in  an  old  case  of  nerve  leprosy  may  have  lost  their  infective  capacity, 
while  a  plentiful  supply  of  bacilli  from  a  fresh  source  and  of  a  more 
virulent  type  might  inoculate  previously  immune  tissues. 

Personally,  the  writer  believes  that  there  are  a  great  many  cases 
of  anaesthetic  leprosy  which  are  abortive  or  which  are  spontaneously 
cured.  On  the  other  hand  it  is  to  be  borne  in  mind  that  anaesthetic 
leprosy,  instead  of  running  a  distinct  course  to  the  end,  may  take  on 
the  severer  and  more  rapidly  fatal  characteristics  of  tubercular  lep- 
rosy. Fortunately,  the  transformation  of  the  milder  anaesthetic  form 
into  the  severer  tubercular  is  comparatively  rare. 

Tubercular  and  Anaesthetic  Leprosy  Contrasted. 

In  order  to  bring  into  strong  relief  the  clinical  contrasts  between 
tubercular  and  anaesthetic  leprosy,  the  more  distinctive  characters  of 
each  may  be  thus  formulated ; 

Tubercular  Leprosy.  Anesthetic  Leprosy. 
.    Bacilli  Bacilli 
Abundant ,  found  in  the  cutaneous  and  Comparatively  few  ;    found    in    nerves 
mucous-membrane    lesions,  physio  and  sheaths,  sparingly  and  not  con- 
logical  secretions,  inguinal  glands,  stantly   in  cutaneous  and  mucous- 
and  the  internal  organs.  membrane  lesions. 

Mode  of  Infection  3fode  of  Infection. 

Unknown,  probably  multiple.  Unknown,  probably  multiple 

Period  of  Incubation.  Period  of  Incubation, 

From  several  months  to  few  years.  Months  and  years,  relatively  longer. 

Prodromes.  Prodroines. 

Fever,  malaise,  epistaxls,  systemic  dis-      More  localized,  hyperaesthesia,  neuralgic 
turbance.  pains,  and  other  sensory  disorders. 

Early  Eruptive  Stage.  Early  Eruptive  Stage 

Erythematous  and  pigmented  spots,  cir-  Erythematous,  pigmented,  and  achromat- 

cular  in  outline,  reddish   in  color,  ic  spots  ;  bulla?,  spots  more  numerous 

which   is  more  pronounced  in  the  and  more  irregular  in  shape,  smaller 

centre,  fading  towards  the  circum-  at  first,  with  a  tendency  to  spread 


TUBEECULAE  AKD  ANESTHETIC  LEPEOSY  CONTEASTED. 


537 


ference  ;  edges  not  raised,  spots  pale 
on  pressure,  transient  in  duration, 
may  appear  and  disappear  a  number 
of  times  before  becoming  the  seat 
of  tubercular  nodules ;  eruption 
more  frequently  appears  on  the  an- 
terior aspect  of  the  body. 


Tvhercular  Stage. 

Development  of  tubercles  in  skin  and 
mucous  membranes,  which  may 
come  out  in  successive  crops,  remain 
permanently  or  disappear  by  inter- 
stitial resorption,  undergo  fibroid 
degeneration,  or  become  ulcerative. 

Ulcerative  Stage. 
Softening  and  breaking  down  of  tuber- 
cles, disappearance  by  purulent  dis- 
solution or  by  resorption  ;  leproma- 
tous  infiltrations  of  internal  organs. 

Mucous  Membranes. 
Seat  of  diffused  and  nodular  infiltra- 
tions followed  by  ulceration;  mu- 
cosa of  eye,  nose,  pharynx,  larynx, 
seat  of  nodular  infiltrations  followed 
by  ulceration. 

Secretory  Glands. 

Sebaceous  and  sweat  secretions,  first  ex- 
aggerated, later  diminished. 

Hair  Follicles. 
Loss  of  eyebrows,  alopecia  of  all  pilous 
surfaces  the  seat  of  tubercular  infil 
tration. 

Nails. 
Often  affected   by  tuberculous  infiltra- 
tions of  matrix  or  ungual  borders, 
followed  by  ulceration,  simulating 
syphilitic  onychia  and  paronychia. 


peripherally  and  serpiginously  and 
form  by  coalescence  large  patches 
which  are  white  and  depressed  in 
the  centre,  with  raised,  well-defined 
hyperchromatic  borders.  These 
patches  are  permanent,  and  remain 
as  long  as  the  disease  lasts.  They 
are  more  numerous  on  the  back  than 
on  the  front  of  the  body. 

Atrophic  Stage. 

Muscular  atrophies,  tendinous  retrac- 
tions, deformities,  paralyses,  with 
sensory  disorders,  anaesthesia,  etc. 


Mutilating  Stage. 
Osseous  degeneration,  loss  of  members 
by  resorption  of  bone,    ulceration, 
gangrene,  perforating  ulcer,  etc. 

Mucous  Membranes. 
Mucous  membranes  not  so  frequently 
affected  ;  changes  not  neoplastic,  but 
essentially  dystrophic ;  eye,  nose, 
pharynx,  and  larynx  more  fre- 
quently exempt. 

Secretory  Glands. 
Primary  exaggeration  of  function  with 
secondary  atrophy  and  suppression 
of  function 

Hair  Follicles 
Loss  of  eyelashes,  bleaching  and  falling 
out  of  hairs  from  atrophy  of  the 
follicles 

Nails. 
Changes  chiefly  atrophic  ,  the  nails  pre- 
serve their  autonomy  in  most  sur- 
prising manner. 


Sensory  Disorders. 

Disorders  of  sensation  not  so  marked  ; 
anaesthesia,  if  present,  is  usually  lo- 
calized, limited  to  the  tubercles  or 
surrounding  regions  ;  probably  due 


Sensory  Disorders. 

Hypersesthesia,  pruritus,  and  pain  pro- 
nounced during  the  early  irritative 
stage,  succeeded  by  numbness  and 
anaesthesia,  more  pronounced  in  mac- 


538 


MOREOW — LEPROSY. 


to  pressure  upon  the  terminal  fila- 
ments of  the  nerves  by  leprous  in- 
filtration. 


Sexual  Functions. 
Sexual  desire  and  capacity  soon  lost ;  im- 
potence from  azoospermia. 

Inguinal  Glands. 

Changes  constant  and  characteristic ; 
thought  to  constitute  centres  of  auto- 
infection. 

Internal  Viscera. 
Seats  of  leprous  infiltration  as  "well  as  of 
tuberculous  and  other  terminal  in- 
fections. 

Course  and  Duration. 
Disease  more  severe,  more  rapidly  pro- 
gressing to  fatal  termination.     Av- 
erage duration,  eiglit  to  ten  years. 

Termination. 
Tuberculous  complications,  exhaustion 
from  leprous  ulcerations,  nephritis, 
colliquative  diarrhcea,  septic  infec- 
tions ;  suffocation  from  atresia  of  air 
passages. 


It  may  be  observed  that  while  the  clinical  pictures  of  the  two 
principal  forms  of  leprosy  present  many  features  of  difference  in  their 
fully  developed  stage,  the  lines  of  demarcation  between  them  are  not 
always  so  clear  or  sharply  drawn  as  would  appear  from  the  above 
differential  table. 

Certainly  during  the  invasion  period  the  prodromal  symptoms  are 
not  sufficiently  distinctive  to  enable  us  to  forecast  the  form  the  dis- 
ease will  eventually  assume.  With  the  advent  of  the  eruptive  stage 
the  divergence  between  the  two  forms  becomes  more  marked.  But 
even  when  we  recognize  a  predominance  of  the  tegumentary  lesions 
on  the  one  hand  or  the  marked  implication  of  the  nervous  system 
on  the  other  we  cannot  say  that  there  will  be  a  fixation  of  one  form  or 
the  other. 

In  order  to  bring  the  distinctive  differences  of  the  two  forms  of 
leprosj'  into  more  prominent  relief  a  typical  picture  of  each  form, 
one  beside  the  other,  may  be  seen  in  Fig.  14.  In  one  it  is  to  be  ob- 
served that  the  visage  is  covered  with  nodular  masses,  marked  by 


ular  patches,  but  may  affect  surface 
of  entire  limbs ;  disassociatiou  of 
modes  of  sensation,  due  to  more  or 
less  complete  degeneration  of  the 
peripheral  nerves. 

Se.nial  Functions. 
Sexual  desire  at  first  exaggerated,  sug- 
gesting satyriasis ;    sexual  capacity 
continued  longer. 

Inguinal  Olands. 
Enlargement  of  glands  exceptional,  not 
probably  due  to  leprous  virus. 

Internal  Viscera. 
Amyloid  degeneration  more  common. 


Course  and  Duration. 
Disease  milder,  less  progressively  ac- 
tive ;  duration  indefinite,  fifteen  to 
twenty  years  or  longer. 

Termination. 

Amyloid  degeneration  of  internal  organs, 
albuminuric  nephritis,  rarely  phthi- 


TUBEECULAE   AXD  ANAESTHETIC   LEPEOSY   CONTBASTED. 


539 


deep  corrugations,  the  lobes  of  the  ears  are  enlarged,  flabby,  and 
pendulous,  but  the  integrity  of  the  extremities  is  completely  pre- 
served; in  the  other  the  bridge  of  the  nose  is  sunken  from  osseous 


Fig.  14.— Contrast  between  Tubercular  and  Anassthetic  Leprosy,  as  Exhibited  in  the  Face, 

Hands,  and  Feet. 


absorption,  the  features  are  drawn  by  facial  paralysis,  the  fingers  are 
distorted  and  mutilated,  and  the  feet  are  mere  stumps,  with  partial 
vestiges  of  the  toes  remaining. 

But  to  demonstrate  the  substantial  identity  of  the  two  forms,  a 
picture  of  mixed  leprosy  is  shown  in  Fig.  15,  in  which  may  be 
observed,  in  addition  to  the  mutilating  changes  in  the  nose,  hands,  and 
feet,  tubercles  on  the  cheek  and  ear.  This  case  was  primarily  anaes- 
thetic, but  after  a  certain  time  tubercular  changes  supervened. 


640 


MORROW — LEPROSY. 


Fig.  15.— Mixed  Leprosy,  Primarily  of  the  Anaesthetic  Type  with  Tubercular  Changes 

Supervening. 


MIXED  OR  COMPLETE  TYPE  OF  LEPROSY.  541 


Mixed  or  Complete  Type  of  Leprosy. 

Under  tliis  designation  are  included  certain  cases  in  which  the 
characteristic  lesions  of  both  the  tubercular  and  anesthetic  forms  ap- 
pear either  simultaneously  or  successively. 

(1)  Symptoms  peculiar  to  both  forms  may  be  present  from  the 
first  in  consequence  of  simultaneous  invasion  by  the  bacilli  of  the 
cutaneous  and  nerve  tissues,  the  course  of  the  disease  being  influenced 
favorably  or  unfavorably  according  to  the  predominance  of  the  nerve 
or  cutaneous  lesions. 

(2)  The  bacilli  may  first  attack  the  peripheral  nerves  and  the  ini- 
tial symptoms  be  those  of  anaesthetic  leprosy.  After  the  disease  has 
run  a  certain  course  it  may  become  complicated  by  the  development 
of  tubercles  and  correspondingly  intensified  in  severity  from  the  inva- 
sion of  the  integument  by  the  bacilli. 

(3)  The  leprous  virus  may  first  affect  the  skin  and  mucous  mem- 
branes with  the  production  of  tubercles  and  other  changes  peculiar  to 
the  tubercular  form,  but  in  the  course  of  its  evolution  the  bacilli 
leave  the  integument  and  invade  the  peripheral  nerves.  The  disease 
then  exhibits  the  milder  symptoms  of  the  anaesthetic  form,  which  is 
less  progressively  active  and  the  duration  of  life  is  considerably  pro- 
longed. 

According  to  Leloir  there  may  be  a  coincident  development  of 
both  forms,  a  transformation  or  a  gradual  transition  of  one  form  into 
the  other,  and  also  a  complete  substitution  of  one  form  for  the 
other;  the  symptoms  of  one  form  replacing  those  of  the  other  pre- 
cisely as  if  a  new  infection  had  taken  place.  In  the  latter  case  it  is 
assumed  that  the  bacilli,  having  exhausted  the  tissue  soil  in  which 
they  first  find  lodgment,  invade  new  tissues  which  were  previously 
immune. 

It  is  probable  that  in  all  of  the  cases  of  reputed  transformation  or 
substitution,  the  symptoms  of  both  forms  may  have  coexisted  without 
recognition,  the  manifestations  of  the  predominant  form  masking 
those  of  the  other. 

The  lines  of  demarcation  between  tubercular  and  anaesthetic  lejD- 
rosy  are  not  so  distinct  and  sharply  drawn  as  to  enable  us  to  separate 
and  classify  them  on  the  basis  of  their  pathogenic  mode.  The  inti- 
mate sympathy  existing  between  the  cutaneous  and  nervous  systems 
in  their  nervous  and  nutritive  relations  explains  the  similarity  in  the 
morbid  phenomena  exhibited  by  each ;  the  more  especially  as  these 
phenomena  are  due  to  the  same  pathogenic  factor. 

The  proportion  of  mixed  cases  varies  in  different  countries.     In 


542  MOKROW — LEPROSY. 

Norway  the  i)roportion  of  nervous  leprosy'  was  33.3  per  cent.,  mixed 
leprosy  15.1  per  cent.,  tubercular  lepros}^  51.6  per  cent.  In  188 
cases  in  British  Guinea  tabulated  by  Hillis  there  were  found  84 
cases  of  tubercular,  51  of  mixed,  and  103  cases  of  nerve  leprosy.  In 
India  Carter's  tables  of  the  relative  frequency  of  the  different  forms 
show  that  9  per  cent,  were  tubercular,  21  mixed,  and  61.9  anaesthetic. 
Impey's  tables  show  that  of  703  patients  admitted  into  the  Robbeu 
Island  Asjdum,  Cape  Colonj',  South  Africa,  there  were  369  anaesthetic 
cases,  238  tubercular  cases,  81  mixed,  and  15  syphilitic,  making  a  per- 
centage of  52.48  anaesthetic,  33.86  tubercular,  11.53  mixed,  and  2.13 
syphilitic  cases. 

Taking  the  observation  of  ten  hundred  and  fifty  cases  which  I  saw 
in  the  Molokai  settlement  in  1889  as  a  basis  of  calculation,  it  may  be 
roughly  computed  that  one-half  were  tubercular,  one-third  anaesthetic, 
and  the  remaining  one-sixth  of  the  mixed  type.  Since  then  the  rela- 
tive proportion  of  anaesthetic  and  mixed  cases  has  largely  increased. 

The  Survival  of  Leprosy  in  Modified  Forms. 

It  is  generally  accepted  that  leprosy  practically  disappeared  from 
Europe  during  the  fifteenth  and  sixteenth  centuries,  and  that  within 
the  last  two  or  three  centuries  cases  of  this  disease  met  with  in  central 
Europe  have  been  imported  cases.  Nevertheless,  it  has  been  contended 
by  certain  authors  of  more  or  less  note  that  certain  rare  forms  of  dis- 
ease occasionally  met  with  in  leprosy-free  countries,  and  which  have 
been  classed  as  distinct  morbid  entities,  represent  survivals  of  leprosy. 

Erasmus  Wilson,  the  distinguished  English  dermatologist,  in  his 
text-book  on  skin  diseases  (1865),  discusses  the  question  whether  the 
leprosy  of  the  Middle  Ages  is  gone  and  left  no  remains  behind. 
"Are  there  no  traces  of  the  great  leprosy  at  the  present  day?"  To 
this  he  answers :  "  It  would  be  contrary  to  all  analogy  to  suppose 
that  it  has  so  totally  passed  away  as  not  to  leave  a  trace ;  and  yet  no 
sign  exists  in  the  records  of  medicine  to  tell  us  that  such  is  not  the 
case.  But  although  the  sign  may  be  absent  in  the  records  of  medi- 
cine, the  infallible  sign  remains  imprinted  on  man.  Leprosy  remains 
among  us  still,  but  only  as  a  faint  trace  of  a  worn-out  disease  or  as 
an  ember  of  the  burnt-out  fire.  God  forbid  that  the  spark  should  be 
rekindled !  I  repeat  that  elephantiasis  still  exists  among  us  in  this 
country  as  a  faint  trace  of  its  former  self,  and  the  observation  of  that 
trace,  however  faint,  becomes  a  matter  of  interesting  search.  Although 
a  mere  shadow  in  comparison  with  the  parent  disease,  it  is  neverthe- 
less sufficient  to  occasion  considerable  annoyance  to  the  sufferer  and 
to  bring  him  not  unfrequently  under  the  inspection  of  the  medical 


THE  SURVIVAL  OF  LEPROSY  IN   MODEFIED  FORMS.  543 

man.  Now  when  once  pointed  out  can  the  medical  man  doubt  or  an 
instant  tlie  nature  of  the  disease  which  he  has  before  him?  There  is 
the  insensibility,  the  deposition,  the  blanching,  the  exhaustion  of 
function,  and  the  atrophy  of  the  parent  malady  with  all  their  original 
distinctness ;  indeed,  one  complete  symptom  of  the  pure  elephantiasis 
preserved  unchanged  as  it  existed  among  the  Jews  and  as  it  is  to  be 
found  at  this  moment  on  the  shores  of  Norway,  the  symptom  which 
was  called  by  the  ancients  morphoea." 

He  declares  that  the  various  forms  of  morphoea  which  he  describes 
under  the  definition  of  morphoea  alba  ladarcea,  morphoea  alba  atro- 
phica, and  morphoea  nigra  are  remains  of  that  bygone  scourge,  the 
great  leprosy.  He  also  declares  that  alopecia  areata  is  a  morphoea 
of  the  scalp  and  the  hair-bearing  skin,  and  that  this  morphoea  bears 
the  same  relation  to  elephantiasis  as  the  morphoea  already  described. 

Kaj)osi  also  includes  the  different  varieties  of  morphoea  in  his 
description  of  the  macular  form  of  leprosy.  He  states  that  the 
several  forms  of  this  spotted  or  macular  leprosy  may  exist  alone  for 
years  as  the  chief  signs  of  the  disease  and  constitute  two  different 
types.  "  Thus,  for  instance,  (a)  they  may  exist  as  such  for  years,  or 
either  terminate  as  such  without  ever  undergoing  any  further  altera- 
tion. To  a  certain  extent  they  represent  local  forms  of  lepra,  since 
during  their  entire  period  of  existence,  as  well  as  after  they  have 
passed  away,  the  system  does  not  become  in  the  least  affected  by 
them.  Or  (b)  they  may  last  for  a  long  time  uncomplicated;  but 
sooner  or  later  the  whole  system  becomes  affected,  and  the  series  of 
symptoms  characteristic  of  anaesthetic  lepra  make  their  appearance, 
among  which  the  sj^mptoms  of  maculated  lepra  occupy  only  a  subor- 
dinate place." 

At  the  present  day  the  most  prominent  advocate  of  the  survival  of 
leprosy  in  Europe  and  elsewhere  under  the  form  of  rare  diseases  is 
Zambaco  Pacha.  In  his  paper  before  the  Berlin  Leprosy  Congress 
he  has  endeavored  to  widen  the  pathological  field  of  leprosy  by  bring- 
ing within  its  domain  syringomyelia,  Morvan's  disease,  scleroderma, 
sclerodactylia,  Raynaud's  disease,  morphoea,  ainhum,  and  progressive 
muscular  atrophy  of  the  Aran-Duchenne  type. 

He  claims  that  in  Europe,  and  in  countries  where  leprosy  has 
ceased  to  exist  as  an  endemic,  it  still  survives  in  a  degraded  form, 
and  that  the  above-mentioned  diseases  constitute  attenuated  or  abor- 
tive types  of  leprosy ;  in  other  words,  they  represent  a  leprosy  "  lar- 
vee,"  modified  and  attenuated  in  its  manifestations.  He  asserts  that 
the  universal  belief  that  leprosy  has  disappeared  for  two  centuries 
from  Central  Europe  and  the  non-recognition  of  the  numerous  varie- 
ties of  this  disease  which  have  been  modified  by  the  progress  of  civi- 


544  MORROW — LEPROSY. 

lization  Lave  contributed  to  engender  errors,  and  that  these  surviving 
forms  of  lepros}'  have  been  designated  under  the  title  of  cases  of  rare, 
nameless,  and  undescribed  forms  of  disease.  While  their  resem- 
blance to  leprosy  has  attracted  the  attention  of  many  distinguished 
observers,  all  have  refused  to  recognize  the  true  nature  of  these  dis- 
eases upon  the  ground  that  they  cannot  be  leprosy,  since  this  affec- 
tion does  not  exist  in  Europe,  and  that  the  patient  has  not  been  in 
any  leprous  locality  where  he  could  have  contracted  the  disease. 

Zambaco  declares  that  Morvan's  disease  is  nothing  less  than  lep- 
rosy, and  that  syringomyelia  and  Morvan's  disease  constitute  one 
and  the  same  thing.  He  thinks  that  there  have  been  confounded 
under  the  title  of  syringomyelia  numerous  cases  of  leprosy  exhibit- 
ing the  anaesthetic  form  of  the  disease.  Progressive  muscular  atro- 
ph}'  of  the  Aran-Duchenne  type  embraces  also  different  diseases, 
among  which  figures  lei^rosy.  Raynaud's  disease  and  symmetrical 
gangrene  depending  upon  nervous  troubles,  circulatory  and  trophic, 
present  the  closest  relations  with  certain  forms  of  lex)rosy.  He  de- 
clares that  one  may  place  with  certainty  among  them  many  cases  of 
leprosy.  He  thinks  it  probable  that  future  research  M'ill  demonstrate 
that  they  are  no  more  than  new  morbid  states  of  a  leprosy-  modified 
and  attenuated  in  its  manifestations.  The  ainhum  of  authors,  when 
affecting  the  hands  or  feet  is,  according  to  Zambaco,  a  form  of  muti- 
lating leprosy.  The  morphcea  of  modern  writers  and  the  mori)hoea 
of  ancient  writers  should  not  be  separated  from  classical  leprosy. 
Scleroderma  and  sclerodactylie  seem  to  him  to  be  only  a  modified 
leprosy,  if  not  an  unmistakable  leprosy  as  one  sees  in  so  many  of  the 
published  cases.  All  of  these  diseases  he  regards  as  more  or  less  de- 
generated forms  of  the  ancient  leprosy,  and  he  endeavors  to  establish 
their  identity  by  grouping  them  under  the  generic  name  of  leprose. 
Although  these  various  diseases  differ  in  appearance,  and  are  some- 
times quite  dissimilar  in  their  extreme  symptoms,  yet  they  approach 
and  blend  in  their  common  sym^jtoms  and  permit  a  pathogenic  uni- 
fication. He  takes  the  ground  that  the  absence  of  anaesthesia  and  of 
the  lepra  bacillus  in  these  diseases  is  not  sufficient  to  make  us  reject 
the  diagnosis  of  leprosy.  The  symptomatology  of  these  newly  created 
diseases  is  merely  an  expression  of  the  polymorphism  of  leprosy. 

It  is  not  possible  within  the  limits  prescribed  for  this  article  to 
enter  into  an  exhaustive  study  of  the  question  of  the  identity  of  these 
diseases  with  leprosy.  It  is  sufficient  to  say  that  the  views  of  Zam- 
baco Pacha  were  not  shared  by  the  great  majority  of  the  leprologists 
present  at  the  Leprosy  Congress. 

It  may  be  said  that  the  above-mentioned  diseases  are  by  no  means 
uncommon  in  the  United  States,  where  leprosy  has  never  existed 


THE   SUEVIVAL   OP  LEPROSY  IN   MODIFIED   FORMS.  545 

except  in  sporadic  and  imported  cases.  The  ancestry  of  many  in- 
dividuals exhibiting  these  diseases  may  be  traced  back  several  gen- 
erations, and  found  to  be  free  from  all  leprous  taint,  while  the  pa- 
tients themselves  have  never  been  exposed  to  contact  with  lepers. 
To  speak  of  a  survival  of  a  disease  which  has  never  existed,  in  this 
country  at  least,  is  a  contradiction  of  terms.  The  assumption  that 
these  diseases  are  expressions  of  leprosy  involves  the  theory  that  the 
leprous  germs  must  have  had  their  origin  in  a  remote  ancestry  and 
remained  latent  for  several  generations  and  then  have  been  trans- 
mitted in  this  modified  form,  which  is  stretching  the  theory  of  atavism 
to  an  impossible  degree. 

In  commenting  upon  the  disappearance  of  leprosj-  from  Europe, 
Jonathan  Hutchinson  says  "  it  is  very  important  to  remark  that,  so 
far  as  our  knowledge  at  present  goes,  it  has  left  nothing  behind  it. 
Vv"e  have  no  half  cases  or  slight  forms  or  modified  maladies.  Its 
manifestations  seem  to  be  somewhat  more  definite  and  positive  than 
those  of  tuberculosis.  It  is  either  leprosy  or  nothing.  Nor  are  there 
any  sporadic  cases  springing  up  here  and  there  in  communities  which 
have  long  been  free. "  The  results  of  the  recent  congress  at  Berlin 
have  strongly  confirmed  these  statements.  No  examples  were  pro- 
duced, with  one  possible  exception  from  a  town  in  Brittany,  show- 
ing that  the  disease  had  occurred  sporadically  in  inland  communities 
otherwise  free.  But  many  examples  were  produced  showing  that  the 
disease  is  and  has  been  for  a  long  time  prevalent  to  a  slight  extent 
in  localities  not  previously  recognized  as  its  haunts. 

The  most  convincing  argument,  however,  which  may  be  adduced 
in  refutation  of  the  views  of  Zambaco  Pacha  is  the  absence  in  all  these 
diseases  of  the  lepra  bacillus.  It  is  generally  recognized  that  the 
presence  of  Hansen's  bacillus  constitutes  the  distinctive  essential 
auatomicopathological  characteristic  of  leprosy.  It  is  the  pathogno- 
monic sign,  and  while  it  is  not  always  practicable  to  demonstrate  its 
presence  in  nerve  leprosy  during  life,  it  is  always  found  at  autopsy. 

The  more  important  differential  features  which  distinguish  these 
diseases  from  leprosy  are  considered  in  the  section  on. Diagnosis. 

PATHOGENY  AND  GENERAL  PATHOLOGY. 

Infection  hy  the  Bacillus. — As  in  the  case  of  other  granulomatous 
processes,  Hansen's  bacillus  attacks  the  various  cellular  elements  of 
the  body  and  is  able  to  penetrate  readily  every  variety  of  cell.  Speak- 
ing generally,  the  changes  induced  in  the  latter  consist  principally  of 
enlargement,  vacuolization,  segmentation  of  the  nucleus,  disappear- 
ance of  pigment.  Multinuclear  and  giant  cells  are  formed  at  times. 
YoL.  XVIII.— 35 


546  MORROW — LEPROSY. 

Homogeneous  yellow  masses  are  formed  at  the  exjoense  of  the  cellular 
contents,  and  the  protoplasm  of  the  cell  may  be  wholly  replaced  by 
the  bacilli.  The  latter  are  situated  both  within  and  between  the 
cells.  The  bacilli  in  time  show  degenerative  changes,  and  we  may 
see  side  by  side  degenerated  bacilli  in  apparently  healthy  cells  and 
young  fresh  bacilli  in  degenerated  cells ;  these  phenomena  are  held 
to  be  illustrations  of  Metchnikoff's  doctrine  of  phagocytosis  and  of 
the  war  to  the  death  between  the  bacilli  and  cells  (Babes).  Of  all 
prominent  histologists,  Uuua  alone  puts  forward  the  claim  that  the 
bacillus  is  entirely  extracellular.  Unna  claims  that  the  regular  and 
constant  seat  of  the  lepra  bacilli  is  extracellular,  their  habitat  not 
being  in  the  protoplasm  of  the  cells,  but  in  the  intercellular  and 
interfascicular  spaces- — the  lymi:)hatic  spaces  in  other  terms.  Almost 
all  other  histologists  who  have  investigated  the  matter  maintain  that 
the  mass  of  bacilli  found  in  sections  or  from  scrapings  of  the  le- 
promes  are  bacilli-bearing  cells — the  leprous  cells  of  Virchow.  They 
see  one  or  many  nuclei  more  or  less  altered  and  a  vacuolized  proto- 
plasm containing  parasites — where  Unna  describes  a  "gloea,"  a  gelat- 
inous or  mucous  substance,  the  product  of  the  secretion  or  degenera- 
tion of  the  bacilli  having  englobed  the  nuclei  of  the  cells  which  limit 
the  spaces  in  which  the  "  gloea"  is  developed.  It  is  probable  that  the 
bacilli  may  be  either  intracellular  or  extracellular,  may  be  comprised 
in  the  preformed  canals  in  which  are  moulded  the  mass  of  bacilli 
comprised  in  the  sheath;  from  this  result  the  "globi"  which  have 
been  mistaken  for  cells. 

During  its  period  of  incubation  or  latency  Hansen's  bacillus  is 
believed,  purely  from  analogy,  to  lie  within  the  lymph  ganglia. 

At  the  moment  when  the  bacillus  is  about  to  attack  the  tissues  it 
is  agreed  by  most  authorities  that  it  occupies  the  lymph  spaces  and 
makes  its  first  assaults  upon  the  endothelia  of  these  cavities.  The 
endothelia  and  perithelia  of  the  lymph  and  blood  capillaries  are,  ac- 
cording to  Babes,  specially  subject  to  attack,  and  the  lumen  of  these 
vessels  often  shows  the  presence  of  the  parasite.  The  fixed  connec- 
tive-tissue cells,  wandering  leucocytes,  plasma  cells,  etc.,  are  in  turn 
attacked.  Wherever  the  parasite  begins  its  assaults  an  inflammatorj^ 
focus  slowly  forms,  consisting  of  round  cells  with  a  single  nucleus. 
While  the  cells  which  lie  within  the  focus  soon  take  on  those  peculi- 
arities of  size,  shape,  and  texture  which  appertain  to  the  specific 
lepra  cell,  and  which  have  already  been  indicated,  there  is  an  outly- 
ing zone  of  ordinary  round-cell  infiltration  which  is  common  to  all 
chronic  inflammation. 


PATHOLOGY   OF   TUBEKCULAR  LEPEOSY.  547 


Tubercular  Leprosy. 

In  this  variety,  wliicli  is  essentially  an  affection  of  the  skin  and 
mucosa,  there  is  present  a  more  or  less  diffuse  infiltration  which 
extends  to  the  subcutaneous  or  submucous  tissues. 

With  regard  to  the  skin,  there  is  an  obvious  but  ill-defined  distinc- 
tion between  ordinary  tubercular  or  mixed  leprosy  and  the  purely 
neurotic  form  which  is  accompanied  by  certain  secondary  cutaneous 
lesions.  While  some  of  the  latter  are  non-specific  and,  as  might  be 
expected,  contain  no  bacilli  (such,  for  example,  as  the  pus  from  a 
perforating  ulcer  of  the  foot),  others  undoubtedly  do  contain  the  para- 
site ;  this  has  been  found  in  the  hypersemic  areas  of  acute  lepra, 
which  often  accompany  the  neurotic  form  and  in  which  Philippson 
found  bacillary  emboli. 

In  the  fresh  eruption  of  anaesthetic  leprosy  bacilli  have  been  found 
both  in  and  beneath  the  skin  and  also  in  the  cutaneous  nerves,  both 
superficial  and  deep.  Babes  believes  that  the  bacilli  are  originally 
present  in  all  the  cutaneous  lesions  in  nerve  leprosy,  but  that  they 
disappear  later.  Darier  has  studied  the  structure  of  the  erythemato- 
pigmentary  macules,  the  so-called  "leprides,"  and  their  contained 
bacilli.  He  demonstrates  a  more  or  less  abundant  infiltration  of  cells 
disposed  in  the  form  of  cylinders  around  the  blood-vessels,  which  in 
certain  regions  may  become  confluent  en  nappe.  These  are,  in  the 
majority,  small  connective-tissue  cells  with  which  are  mingled  in 
variable  jjroportions  white  corpuscles,  plasma  cells,  some  mastzellen, 
and  in  rare  cases  giant  cells.  In  nine  cases  which  he  examined  he 
found  in  all  but  one  the  presence  of  bacilli,  whether  the  patches  were 
recent  or  ancient,  erythematous  or  purely  pigmentary.  The  bacilli  in 
some  cases  were  scarce,  in  others  almost  innumerable.  Darier  claims 
that  the  almost  pathognomonic  structure  of  the  macules,  and  the 
almost  constant  presence  of  the  bacilli  in  their  interior  permit  of  an 
early  diagnosis,  which  is  scientifically  certain. 

In  tubercular  leprosy  proper  the  anatomical  appearances  vary 
considerably  in  proportion  as  the  deposit  is  recent  or  old.  Young, 
fresh  nodules  lie  somewhat  removed  from  the  epidermis,  a  broad  stra- 
tum of  normal  skin  intervening.  The  infiltration  begins,  as  do  similar 
granulomatous  processes,  about  the  pilosebaceous  follicles,  vessels, 
nerves,  and  sweat  glands ;  and  one  or  the  other  of  these  structures 
forms  the  centre  of  the  future  nodule.  Besides  these  specific  foci  the 
skin  in  general  about  the  latter  is  the  seat  of  ordinary  simple  round- 
cell  infiltration.  This  infiltration  may  be  diffuse  without  a  marked 
nodular  disposition.     Sections  of  recent  leprous  tubercles  show  the 


548  MORROW — LEPROSY. 

layers  of  the  epidermis  perfectly  preserved  and  normal.  The  papilleo 
are  somewhat  hypertrophied  and  filled  with  small  round  cells.  In 
old  tubercles  the  papillary  outlines  liave  disappeared  and  the  entire 
stratum  is  replaced  by  a  uniform  layer  of  small  cells.  The  entire  der- 
mal tissue  is  infiltrated  with  round  or  ovoid  cells  which  are  here  and 
there  grouped  in  illy  defined  masses  and  penetrate  into  the  cellular 
adipose  tissue.  The  adventitious  tunics  of  the  blood-vessels,  as  also 
their  internal  layers,  are  thickened  and  their  calibre  is  narrowed. 
The  sebaceous  and  sudoriparous  glands  are  implicated  and  choked 
by  the  production  of  small  cells  formed  at  their  periphery  and  end  by 
atrophying  and  finally  disappearing. 

The  bacilli  are  found  not  only  in  the  blood-vessel  cells,  but  also 
outside  of  cellular  formations  in  the  lymphatic  spaces.  The  cells 
designated  as  "  lepra  cells"  by  Virchow  are  found  in  the  dermal  groups 
of  old  tubercles.  These  voluminous  cells  possess  several  nuclei; 
they  are  ovoid,  spherical,  or  irregular,  and  sometimes  as  large  as  the 
giant  cells  of  tuberculosis,  with  which  they  may  be  confounded.  In 
old  tubercles  the  epidermis  is  thinned,  the  i3apillary  layer  is  effaced, 
and  no  trace  of  the  glands  or  hair  follicles  remains. 

As  the  nodules  progress  they  approach  nearer  to  the  epidermis, 
increasing  at  the  periphery,  while  degenerative  changes  take  place  io 
the  characteristic  cells  and  the  centre  becomes  necrotic.  The  casting 
out  of  this  slough  leaves  an  ulcer.  The  slough  is  made  up  of  degen- 
erated cells  and  colonies  of  bacilli  and  is  due  to  the  action  of  the  tox- 
ins formed  by  the  latter.  The  ulcer  may  readily  heal,  or  the  outlying 
inflammatory  zone  may  undergo  the  leprous  transformation,  so  that 
the  ulcer  may  increase  in  size  and  depth. 

Appendages  op  the  Skin. 

Next  should  be  considered  the  action  of  the  bacillus  upon  the  hair 
follicles,  vessels,  nerves,  epidermis,  and  sweat  glands. 

The  bacillus  appears  to  have  a  special  x^redilection  to  settle  about 
the  hair  follicles,  and  perifollicular  foci  of  disease  result,  with  exten- 
sion of  the  process  through  the  wall  of  the  follicle.  The  bacilli  are 
also  encountered  in  the  hair  papillae,  and  hair  formation  is  arrested, 
causing  the  loss  of  hair  on  the  surface  of  the  body  and  especially  the 
falling  of  the  eyebrows.  The  bacilli  are  also  found  in  the  sebaceous 
glands  which  communicate  by  their  excretory  ducts  with  the  hair  fol- 
licles. It  results  from  this  disposition  that  the  bacilli  situated  in  the 
sebaceous  glands,  in  the  hair  papillas,  and  in  the  sheath  of  the  fol- 
licle may  migrate  along  the  follicle  and  thereby  reach  the  free  surface 
of  the  skin.     It  is  possible  that  they  may  penetrate  the  skin  from  the 


PATHOLOGY  OF  TUBERCULAR  LEPROSY.  549 

outside  by  the  same  channels.  The  follicle  is  very  little  altered  by 
the  disease,  but  its  epithelia  show  slight  proliferation,  which  accords 
with  the  action  of  the  bacilli  upon  other  epithelial  tissue.  The  bacilli 
are  not  invariably  found  in  the  hair  follicles  or  the  sebaceous  glands 
in  connection  with  them ;  Cornil  and  Babes,  indeed,  say  that  they  are 
encountered  there  but  rarely.  With  regard  to  the  sebaceous  glands 
in  general,  the  epithelia  at  first  proliferate,  but  the  glands  are  ulti- 
mately destroyed.  Bacilli  are  not  found  in  the  interior  of  the  sudo- 
riparous glands. 

Aside  from  the  phenomena  of  essential  nerve  leprosy,  the  terminal 
nerve  fibres  within  the  skin,  being  an  integral  part  of  the  latter,  un- 
dergo special  alterations  during  the  general  infiltration  of  tubercular 
leprosy.  These  terminal  nerves  are,  like  the  hair  follicles,  predilec- 
tion tissues  of  the  bacillus.  Both  afferent  and  effereiit  nerves  and 
Pacinian  corpuscles  are  attacked  and  at  times  undergo  remarkable 
changes,  the  smallest  fibres  becoming  thick  cellular  cords,  and  all 
these  structures  show  an  invasion  of  bacilli  with  new  formation  of 
connective  tissue  and  blood-vessels  and  degeneration  of  the  essential 
nerve  substance  with  occasional  regeneration.  In  mixed  leprosy  these 
phenomena  are  associated  with  secondary  changes  in  the  terminal 
nerves  due  to  disease  of  the  parent  trunk. 

When  the  bacilli  reach  the  epidermis  and  attack  it  directly,  we 
have,  according  to  Babes,  proliferation  of  the  keratogenous  cells  alone 
or  of  the  mucoiDapillary  layer.  In  the  former  case  leprous  tylosis 
results,  and  in  the  latter  leprous  warts  develop. 

Still  more  remarkable  is  the  action  of  the  bacillus  upon  the  sweat 
glands.  Side  by  side  with  proliferation  of  the  interstitial  connective- 
tissue  stroma  of  the  gland  we  see  new  formation  of  the  glandular  epi- 
thelia, and  we  are  therefore  justified  in  speaking  of  leprous  adenoma 
or  adenoleproma.  The  fact  that  the  bacillus  is  able  to  cause  prolifera- 
tion of  all  epithelial  tissues,  as  well  as  of  the  fibrous  tissues,  seems 
to  justify  the  claim  that  the  action  of  the  bacillus  in  a  leper  may  be 
sufficient  to  cause  epithelioma,  which  is  occasionally  observed. 

It  is  thus  seen  that,  while  the  maximum  intensity  of  the  toxins 
tends  to  cause  destructive  lesions  through  terminal  necrosis  of  the  in- 
filtration leading  to  ulceration,  every  variety  of  constructive  lesion 
may  coexist,  due  to  proliferation  of  most  of  the  anatomical  elements 
of  the  skin.  Further,  some  of  the  destructive  lesions  undergo  partial 
repair  (cicatrization  of  ulcers,  sclerotic  changes,  regeneration  of 
nerves),  and  when  we  add  trophic  alterations  due  to  disease  of  the 
nerve  trunks  and  centres  and  the  results  of  the  action  of  associated 
microorganisms  (pyo'genic  cocci,  etc.)  it  becomes  evident  that  the 
pathology  of  cutaneous  leprosy  is  extraordinarily  complex. 


550  MOKEOW — LEPROSY. 


The  Mucous  MEiiBRANEs. 

Following  the  law  that  the  parts  most  frequently  affected  are  also 
earliest  affected,  we  must  regard  the  nasal  and  laryngeal  mucosae  as 
specially  predisposed  to  leprosy.  The  structures  about  the  fauces 
possess  more  immunity,  and  the  posterior  wall  of  the  pharynx  most 
of  all. 

Leprous  changes  are  most  characteristically  seen  in  the  nasal 
mucous  membranes,  and  the  pathological  alterations  in  these  now  to 
be  described  will  apply,  with  certain  modifications  due  to  peculiari- 
ties of  anatomical  structure,  to  the  mucosa  of  the  upper  air  pass- 
ages. 

Leprosy  in  this  locality  is  characterized  not  only  by  its  early  and 
almost  constant  appearance,  but  by  its  very  rajjid  course,  which  leads 
to  destructive  lesions  at  a  stage  when  alterations  of  other  tissues  of 
the  bod^"  are  in  their  formative  period. 

Authorities  dift'er  very  widely  as  to  the  pathology  of  nasal  lepra, 
and  these  differences  of  oj^inion,  taken  in  conjunction  with  the  recently 
asserted  claims  of  the  existence  of  primary  leprous  foci  in  the  nose, 
tend  to  give  the  entire  subject  a  uuiciue  irapoi-tance. 

Kaposi  regards  the  pathological  alterations  in  this  locality  as 
symptomatic  rather  than  specific.  Some  regard  the  specific  infiltra- 
tion as  confined  to  the  anterior  portion  of  the  nose,  and  others  find  it 
everywhere. 

It  has  usually  been  stated  that  while  the  cartilages  are  almost  con- 
stantly attacked  the  bones  are  never  directly  affected,  biit  Gliick's 
numerous  autopsies  show  that  every  bone  in  the  osseous  nasal  frame- 
work may  suffer  directly.  The  same  observer  also  refutes  the  preva- 
lent view  that  the  nose  is  not  affected  in  anaesthetic  leprosy.  During 
the  first  outbreak  of  tubercular  leprosy  anterior  rhinoscopy  reveals  a 
shining  and  congested  mucous  memljrane.  As  there  appears  to  be 
a  great  discrepancy  of  opinion  as  to  this  stage  of  leprosy,  it  may  be 
well  to  follow  Babes,  who  states  that  the  initial  manifestations  consist 
of  a  diffuse  and  hardly  perceptible  leprous  infiltration  i)rincipally 
affecting  the  mucosa  of  the  septum  and  lower  turbinate  body ;  this  is 
accompanied  by  redness,  induration,  and  increased  secretion,  and  the 
latter  may  rapidly  dry  and  contain  abundant  bacilli. 

As  for  the  subsequent  stages  of  complete  infiltration  with  partial 
resolution,  destructive  terminal  alterations  and  collateral  attempts  at 
repair,  hardly  any  two  authorities  draw  the  same  picture.  We  may 
feel  assured  that  the  early  infiltration  may  vary  greatly.  The  deposit 
may  be  miliary  or  pea-sized,  or  may  even  exceptionallj-  consist  of  a 


PATHOLOGY  OF  TUBERCULAR  LEPROSY.  551 

single  leprous  tumor  large  enough  to  block  the  nostril  and  push  the 
septum  over  into  the  ojjposite  nasal  chamber.  This  single  large 
leproma  is,  of  course,  analogous  to  the  tuberculous  tumor  described 
by  rhinologists. 

From  analogy  there  can  be  little  doubt  that  in  an  organ  like  the 
nose  there  must  be  two  sets  of  manifestations,  one  specific  and  the 
other  symptomatic.  With  regard  to  the  leprous  nodules,  if  they  are 
small  and  scattered,  it  doubtless  follows  that  a  certain  amount  of  reso- 
lution takes  place.  While  the  course  of  leprosy  in  the  nose  is  acute, 
authorities  appear  to  agree  that  leprosy  here,  as  elsewhere,  may 
occur  in  successive  outbreaks,  and  that  the  earlier  infiltration  may 
be  absorbed  or  may  at  any  rate  stop  short  of  ulcerative  or  retrograde 
changes. 

During  this  benign  cycle  the  nasal  mucosa  can  hardly  avoid  ex- 
hibiting evidences  of  symptomatic  rhinitis.  The  localized  leprous 
deposit  must  certainly  be  surrounded  by  areas  of  simple  infiltration 
with  thickening  and  increased  secretion — in  a  word,  hyperplastic 
rhinitis  hardly  differing  from  the  same  condition  as  it  occurs  under 
very  different  circumstances;  and  this  hyperplastic  stage  must  inev- 
itably be  followed  by  induration  and  sclerotic  changes.  All  this  is 
very  obvious  from  the  repeated  statements  of  some  authors,  that  nasal 
leprosy  may  occasionallj'-  terminate  in  a  general  sclerosis  of  the 
mucosa,  without  entering  into  any  ulcerative  or  destructive  lesions. 
Other  authors  speak  of  simple  atroph}^  of  the  turbinates  and  amplifi- 
cation of  the  nasal  chambers.  In  a  word,  in  these  benign  and  self- 
limited  cases  we  have  a  picture  not  unlike  ordinary  hyperplastic  and 
atrophic  rhinitis.  It  is  probable  that  this  condition  is  exceptional, 
for  a  number  of  authorities  do  not  describe  it.  The  course  of  nasal 
leprosy  being  acute  and  quasimalignant  as  a  rule,  it  is  evident  that 
the  leprous  infiltration  tends  to  be  extensive  and  that  the  specific 
manifestations  usually  predominate  over  the  symptomatic.  We  may 
assume  that  the  leprous  nodules  are  prone  to  excoriation  and  later 
to  ulceration,  and  that  there  is  a  discharge  which  is  largely  derived 
from  these  excoriated  or  ulcerated  surfaces,  and  w^hich  may  tend  to 
form  bloody,  adherent  crusts,  which  may  occlude  the  nostrils  and  be 
detaclied  with  difficulty,  or  may  occasionally  flow  from  the  nose. 
One  of  the  results  of  this  stage  or  degree  of  leprous  rhinitis  which  is 
generally  spoken  of  is  the  destruction  of  the  columnar  epithelia  of 
thelia  of  the  nasal  mucosa ;  and  after  this  stage  of  the  disease,  no 
matter  to  what  further  length  it  proceeds,  the  lining  membrane  un- 
dergoes a  so-called  "cutisation"  which  is  almost  universally  men- 
tioned in  describing  the  nose  in  cases  of  inveterate  leprosy — the 
membrane  taking  on  the  appearances  of  the  skin. 


552  MORROW — LEPROSY. 

This  "cutisation"  inaj  not  differ  esseutiallj'  from  the  sclerosis 
which  has  been  mentioned  as  accompanying  a  relatively  benign  termi- 
nation of  the  disease  in  so  far  that  both  processes  involve  a  transfor- 
mation of  the  columnar  epithelial  elements  into  the  squamous  form ; 
but  the  former  seems  to  result  purely  from  specific  changes  and  to 
accompany  every  case  of  inveterate  leprosy,  whereas  the  other  process 
does  not  differ  materially  from  that  observed  to  follow  simple  hyper- 
plastic rhinitis  followed  by  sclerotic  changes,  and  is  evidently  of 
exceptional  occurrence. 

Given  that  sooner  or  later  in  the  typical  case  the  nasal  mucosa  is 
largely  occupied  by  a  diffuse  granulomatous  infiltration  chiefly  spe- 
cific in  nature,  the  terminal  lesions  of  the  disease  depend  wholly  upon 
the  i^redominance  respectively  of  the  destructive  or  conservative  proc- 
ess. If  the  granulation  tissue  tends  to  increase  with  only  superficial 
ulceration,  and  with  more  or  less  cicatricial  and  sclerotic  change,  the 
nasal  chambers  are  gradually  occluded  by  the  neoplastic  tissue  so 
that  the  so-called  concentric  narrowing  of  the  nasal  fossae  results. 
Here  the  mucosa  of  the  septum,  floor,  and  turbinates  is  equally  en- 
larged and  the  nasal  passage  is  largely  obliterated.  The  phenomena 
of  concentric  narrowing  and  cutisation  are  mentioned  by  authors  in 
large  numbers  of  clinical  histories  of  old  leprosy.  Another  even 
more  characteristic  phenomenon  has  not  yet  been  referred  to,  viz., 
absorption  of  more  or  less  of  the  septal  cartilage,  which  is  extremely 
common.  While  this  may  be  due  also  to  other  causes,  it  undoubtedly 
is  often  due  to  pressure  upon  both  sides  by  the  fungatiug  granulo- 
matous mass  which  has  infiltrated  the  mucosa.  Atresia  of  the  nostril 
may  be  brought  about  in  a  manner  similar  to  occlusion  of  the  nasal 
fossae,  and  it  appears  that  all  the  foregoing  changes  of  concentric  nar- 
rowing, occlusion  of  the  nostril,  absorption  of  the  septal  cartilage, 
cutisation,  etc.,  may  occur  without  previous  extensive  ulceration, 
which  latter  phenomenon  is  somewhat  less  typical. 

While  a  moderate  degree  of  ulceration  is  sufficient  to  perforate 
the  septum  in  many  cases  when  the  disease  is  by  no  means  far  ad- 
vanced, these  shallow  ulcers  which  often  heal  over  would  not  mate- 
rially alter  the  picture  which  has  already  been  described.  More  ex- 
tensive forms  of  ulceration,  however,  occur  at  times,  the  ulcers  being 
larger  and  deeper,  and  under  these  circumstances  the  turbinated 
bones  maj'  be  destroyed  outright,  and  extensive  destruction  of  any  of 
the  hard  and  soft  parts  may  result ;  and  when  these  large  and  deep 
ulcers  cicatrize,  we  may  have  deformity  of  the  nostrils  or  adhesions 
between  the  outer  and  inner  walls  of  the  nasal  fossae. 

All  these  tj-pes  of  advanced  lesions  of  the  inner  aspect  of  the  nose 
have  their  counterpart  in  infiltrating  and  destructive  lesions  of  the 


PATHOLOGY  OF  TUBERCULAR  LEPROSY.  553 

outer  nose ;  Gliick  lias  described  and  illustrated  several  types  of  de- 
formity due  to  botli  external  and  internal  lesions:  the  nose  may  be 
twisted  to  one  side,  it  may  be  flattened  like  tlie  negro  nose,  or  it  may 
overliang  tlie  upper  lip. 

The  Internal  Organs. 

Lymioh  Ganglia. — The  cervical,  axillary,  and  inguinal  glands  are 
most  commonly  affected,  with  occasionally  the  visceral  (mediastinal 
and  retroperitoneal).  The  ganglia  are  enlarged  and  show  cheesy  or 
hyaline  foci,  and  in  old  cases  chalky  deposits  with  sclerotic  changes. 
The  adenoid  tissue  wholly  disappears. 

Blood-vessels. — Peri-  and  endoarteritis  and  phlebitis  occur,  with 
resulting  narrowing  of  the  lumen  and  at  times  thrombosis.  These 
changes  are  usually  due  to  the  proximity  of  leprous  foci,  but  the  fact 
that  vessels  become  leprous  when  no  such  foci  are  near  appears  to 
show  that  metastases  must  occur  through  the  circulation.  Gliick  has 
called  attention  to  the  lesions  of  the  large  subcutaneous  veins,  which 
he  declares  are  by  no  means  rare.  Leprous  phlebitis  is  manifest  in 
the  form  of  a  nodose  tract,  distinctly  limited,  sometimes  without 
any  connection  with  neighboring  tubercles,  occupying  any  portion  of 
the  vein  which  may  be  healthy  above  or  below;  sometimes  a  series 
of  nodose  lesions  may  be  observed  u^Don  the  same  vein.  Upon  histo- 
logical examination  after  excision,  there  are  found  thickening  of  the 
adventitia,  with  infiltration  of  small  cells  in  the  muscular  coat,  and 
considerable  thickening  of  the  endo-vein  wdth  new  formation  of  the 
capillaries.  In  all  the  tumors,  and  even  in  the  endothelium,  bacilli 
are  abundantly  present  with  their  characteristic  disposition.  Gliick 
contends  that  the  bacilli  may  penetrate  the  walls  of  the  vessels  from 
without. 

Spleen. — Bacilli  are  always  present  here,  even  when  no  pathologi- 
cal changes  are  evident.  When  the  spleen  is  structurally  altered  the 
lesions  are  analogous  to  those  observed  in  the  lymph  ganglia.  Joseph 
found  large  quantities  of  bacilli  in  the  spleen  in  cases  in  which  the 
most  minute  research  could  not  detect  them  in  the  liver,  kidneys,  or 
other  viscera.  He  suggests  a  relation  between  the  abundant  pres- 
ence of  the  bacilli  in  this  organ  and  its  function  in  the  formation  of 
blood. 

Bone  llarroiv. — The  fatty  tissue  disappears  and  the  marrow  be- 
comes firm  and  takes  on  the  appearance  of  hsematopoiesis.  Hsemato- 
blasts,  new-formed  capillaries,  nucleated  red  blood  corpuscles,  prolif- 
eration of  large  round  cells,  and  myeloplaxes  occur. 

Lungs. — The  lungs  of  lepers  are  either  normal   or  exhibit  the 


554  MORROW — LEPROSY. 

lesions  of  tuberculosis.  Leprous  foci  may,  however,  occasionally 
occur.  They  consist  of  thickening  of  the  interstitial  tissue  with 
compression  and  obliteration  of  the  alveoli. 

Intestine. — The  intestinal  ulcers  often  found  in  leprosy  are  tuber- 
culous, but  occasionally  true  leprous  lesions  have  been  met  with 
(eroded  nodular  areas) .  Bacilli  have  been  found  in  ordinary  intes- 
tinal mucus. 

Liver. — In  the  liver  we  get  increase  in  the  volume  of  the  intersti- 
tial tissue,  with  new  formation  of  the  radicles  of  the  bile  ducts. 
Amyloid  degeneration  has  occasionally  been  recorded. 

Kidneys. — Bacilli  have  been  foimd  in  the  tumefied  endothelium  of 
the  vessels  of  the  kidney,  especially  in  the  glomeruli  and  also  in  the 
suprarenal  bodies. 

Babes  has  found  the  bacillus  in  the  brain,  pancreas,  hypophysis 
cerebri,  thyroid,  prostate,  and  in  tissues  which  were  apparently  alto- 
gether healthy. 

Female  Breast. — In  tubercular  leprosy  the  bacillus  has  been  found 
in  the  milk.  In  cutaneous  lepros}^  the  infiltration  extends  inwards 
along  the  ducts,  and  often  penetrates  the  membrana  propria  and 
epithelial  layer.  Bacilli  have  been  found  free  in  the  acini  and 
ducts. 

Testicle. — This  is  a  locality  of  early  and  constant  implication. 
The  gland  is  often  affected  when  apparently  normal,  and  its  fnuction 
may  be  compromised  or  entirely  destroyed  during  the  first  or  second 
year  of  the  disease.  In  a  typical  case  the  changes  are  chiefly  inter- 
stitial— proliferation  of  the  intercanalicular  septa  and  membrana 
propria,  with  resulting  compression  of  the  canaliculi.  Necrotic  foci 
may  appear  in  the  infiltration.  The  cord  remains  intact  for  a  long 
time. 

Ovaries. — Bacilli  have  been  found,  but  not  under  such  circum- 
stances that  sexual  infection  could  be  assumed.  There  are  but  few 
bacilli  to  be  found  and  few  anatomical  changes. 


Anaesthetic  Leprosy. 

The  appearance  of  the  nerves  in  leprosy  varies  extremeh'  accord- 
ing to  the  kind  of  leprosy,  stage  of  the  disease,  and  size  of  the  nerve 
invaded.  Even  in  ordinary  leprosy  of  the  skin,  when  the  terminal 
nerves  are  involved  as  part  of  the  general  infiltration,  bacilli  may  be 
found  higher  up  in  the  course  of  the  nervo  trunks,  while  in  certain 
infiltrated  patches  of  skin  the  bacilli  and  neoplastic  tissue  may  be 
confined  to  the  skin  and  their  immediate  periphery. 


PATHOLOGY   OF   AX^STHETIO  LEPEOST.  655 

The  diseased  nerves  appear  greatly  tliickened,  both  the  peri-  and 
endoneurium  having  undergone  proliferation.  This  infiltration  is 
characterized  by  the  presence  of  large,  round,  or  elongated  cells,  con- 
taining the  bacilli  more  or  less  abundantly.  Between  the  atrophy- 
ing nerve  fibres  or  replacing  them  are  found  large  fusiform  spaces, 
which  are  replete  with  colonies  of  bacilli.  In  the  smaller  peripheral 
nerves,  then,  we  fijid  proliferation  of  the  epi-  and  endoneurium,  with 
retrograde  changes  in  the  nerve  fibres. 

In  the  large  trunks,  such  as  the  median,  we  find  proliferative 
changes  in  the  epineuiium,  in  the  connective-tissue  septa,  between 
the  bundles  of  nerve  fibres,  and,  finally,  in  the  special  investment  of 
individual  fibrillfe.  The  cellular  elements  arise  chiefly  from  the  endo- 
thelia  of  the  vessels  and  fixed  connective-tissue  cells.  The  bacilli  in 
the  nerves  lie  between  rather  than  within  the  cells,  and  may  be  found 
within  Schwann's  sheath.  The  nerve  elements  proper  show  numer- 
ous retrograde  changes. 

Spbwl  and  Sympathetic  Ganglia. — Bacilli  occur  within  the  large 
cells  of  the  spinal  ganglia,  lying  within  vacuoles.  They  are  less 
numerous  in  the  sympathetic  ganglia.  Nearly  all  the  bacilli  lie 
within  the  cells,  but  in  certain  cases  the  capsule  and  interstitial  con- 
nective tissue  are  affected,  and  the  ganglia  in  these  cases  are  thick- 
ened. A  remarkable  fact  is  that  the  nerve  fibres  which  are  continu- 
ous with  the  ganglia  as  well  as  the  blood-vessels  appear  to  be  free  from 
bacilli. 

Spinal  Cord. — Single  bacilli  may  occur  in  perfectly  normal  gan- 
glionic cells ;  eventually  they  lead  to  disappearance  of  the  chromatic 
substance  and  pigment,  and  of  the  nucleus  itself.  Vacuolization  is 
general  throughout  the  cell. 

The  presence  of  bacilli  in  the  cord  is  not  known  to  cause  any  spe- 
cial symptoms.  Babes  found  bacilli  in  the  cord  in  nine  cases,  three 
times  in  the  anterior  horns ;  in  pure  lepra  nervosa  the  bacilli  have 
never  been  found  in  the  cord.  On  the  other  hand,  the  spinal  ganglia 
are  almost  invariably  implicated  in  nerve  lepra.  Owing  to  the  exten- 
sive implication  of  the  peripheral  nerves,  it  is  difficult  to  determine 
the  influence,  if  any,  of  ganglionic  leprosy.  The  presence  of  bacilli 
in  the  spinal  cord  has  naturally  an  important  bearing  in  connection 
with  the  origin  of  syringomyelia  and  also  in  the  interpretation  of 
the  pathogeny  of  the  habitual  symmetry  of  anaesthesia  and  the  amyo- 
trophic disorders  of  leprosy. 

Jeanselme,  in  two  out  of  five  autopsies,  found  a  pronounced 
degeneration  of  the  posterior  column,  and  in  one  of  the  cases  similar 
changes  in  one  of  the  lateral  columns.  The  topographic  disposition 
explains,   he  thinks,   certain   tabetiform  troubles  which  havo  been 


556  MORROW— LEPROSY. 

observed  in  leprosy.  The  whole  question  of  the  relations  of  the  lep- 
rous process  to  disorders  of  the  central  nervous  system  is  unsettled 
and  involved  in  much  obscurity.  There  is  a  marked  divergence  of 
opinion  between  histologists  as  to  the  interpretation  of  the  nervous 
manifestations.  Dehio,  Looft,  and  others  claim  that  the  nerves  are 
always  invaded  by  their  peripheral  extremities,  and  that  their  infec- 
tion as  well  as  their  degeneration  always  follows  a  centripetal  course, 
with  successive  imi)lication  of  the  motor  and  sensory  collateral 
branches.  Darier  has  suggested  the  probability  that  the  patho- 
genic process  is  not  the  same  in  all  cases — that  sometimes  the  centres, 
sometimes  the  peripheral  nerves  may  be  primarily  invaded  by  the 
bacillary  proliferation. 

DIAGNOSIS. 

A  retrospective  diagnosis  of  the  diseases  formerly  classed  as 
leprosy  would  show  that  a  vast  number  of  ordinary  dermatoses  were 
included  in  this  category.  In  the  light  of  our  present  knowledge  it 
would  appear  that  the  leprosy  of  Mosaic  times  embraced  vitiligo, 
psoriasis,  scabies,  certain  forms  of  eczema,  and  perhaps  other  dis- 
eases. 

In  the  Middle  Ages  the  greatest  chaos  and  confusion  prevailed  in 
the  classification  of  diseases  of  the  skin.  On  account  of  the  vague- 
ness of  the  terms  then  used  in  describing  skin  diseases,  and  the  dif- 
ference in  the  signification  attached  to  them  in  modern  dermatological 
nomenclature,  it  would  be  impossible  to  indicate  accurately  what  the 
leprosy  of  that  period  included.  It  is  very  jjrobable  that  the  popula- 
tion of  the  iiumerous  leproseries  which  were  established  in  various 
parts  of  Europe  during  mediaeval  times  was  largely  swollen  by  the 
inclusion  of  a  vast  number  of  persons  suffering  from  diseases  of  the 
skin  of  an  entirely  different  character— many  of  them  not  in  the  re- 
motest degree  contagious.  It  is  very  certain  that  manj'  types  of  dis- 
ease which  have  recently  been  recognized  as  distinct  morbid  entities 
were  confounded  with  leprosy,  such,  for  example,  as  syringomyelia, 
morphoea,  scleroderma,  mycosis  fungoides,  and  Raynaud's  disease. 
It  is  \erj  probable  that  psoriasis,  pemphigus,  pellagra,  scrofula,  lu- 
pus, syphilis,  aad  other  diseases  which  presented  some  objective 
resemblance  to  lei)rosy  were  classed  with  the  latter  disease. 

One  of  the  most  mysterious  problems  in  the  history  of  medicine, 
which  has  not  yet  received  a  definite  solution,  was  the  sudden  appari- 
tion of  syphilis  in  Europe  towards  the  close  of  the  fifteenth  century, 
and  the  displacement  of  leprosy  by  the  new  disease.  There  can  be 
no  doubt  that  the  multitudinous  cutaneous  manifestations  of  syphilis 
and  their  similitude  to  leprosy,  a  similitude  rendered  more  striking 


DIAGNOSIS.  557 

by  tlie  epidemic  violence  -with  wliicli  syphilis  then  raged,  furnished 
an  admirable  field  for  error,  and  that  syphilitics  contributed  a  large 
contingent  to  the  resident  population  of  the  leper  houses.  Guy 
Patin  tells  us  that  at  the  beginning  of  the  sixteenth  century  "the 
leproseries  were  filled  with  syphilitics."  The  extent  to  which  leprosy 
prevailed  in  Europe  during  the  Middle  Ages  and  the  actual  number 
of  lepers  imprisoned  in  the  nineteen  thousand  leper  houses  were 
doubtless  magnified  by  the  indiscriminate  segregation  of  all  per- 
sons whose  symptoms  bore  any  resemblance  to  those  of  leprosy. 

The  clinical  picture  of  leprosy  which  is  drawn  by  text-book  writers 
of  the  present  day  is  that  of  a  disease  which  is  as  readily  recognizable 
by  its  typical  features  as  it  is  repulsive  by  its  hideous  deformity. 
This  common  conception  is  derived  from  examples  or  representations 
of  the  disease  in  its  fully  developed  or  final  stage.  With  its  initial 
manifestations  and  the  varied  phenomena  exhibited  in  the  earlier  stage 
of  its  evolution,  few  medical  men  except  those  resident  in  leprous 
countries  are  familiar.  While  it  is  undoubtedly  true  that  the  clinical 
features  of  a  case  of  tubercular  leprosy,  typical  in  its  development 
and  advanced  in  its  evolution,  are  so  striking  and  characteristic  as  to 
be  absolutely  pathognomonic,  it  is  equalh^  true'  that  in  its  earlier 
stages,  and  even  in  fully  developed  cases  with  atypical  manifestations, 
there  is  no  disease  in  the  entire  domain  of  pathology  more  difficult 
of  recognition. 

This  observation  applies  with  still  more  force  to  anaesthetic  lep- 
rosy. Reference  has  already  been  made  to  many  forms  of  disease 
which  have  but  recently  been  recognized  as  distinct  types,  but  which 
imitate  the  phenomena  of  nerve  leprosy  so  accurately  that  the  differ- 
entiation cannot  always  be  established  from  the  objective  characters 
or  the  sensory  disorders.  This  similitude  is  so  marked  that  certain 
leprologists  maintain  that  these  diseases  are  survivals  of  leprosy  and 
represent  abortive  or  degraded  forms  of  the  disease.  Even  so  distin- 
guished an  authority  as  Erasmus  Wilson  declared  in  1862  that  the 
various  forms  of  morphoea  and  alopecia  areata  are  manifestations  of 
leprosy.  Kaposi  also  describes  morphoea  as  a  form  of  macular 
leprosy.  Eastlander  regards  mal  perforant  as  the  last  vestige  of  lep- 
rosy in  France. 

The  difficulties  which  attend  the  diagnosis  of  leprosy  depend  upon 
its  prolonged  period  of  incubation,  the  absence  of  any  initial  lesion 
that  might  connect  it  with  a  known  exposure,  the  indeterminate  char- 
acter of  its  prodromal  symptoms,  and  finally  the  multiplicity  and 
banality  of  its  manifestations.  The  fact  that  leprosy  is  essentially  a 
proteiform  malady  is  not  sufficiently  appreciated.  While  syphilis 
may  surpass  it  in  the  number  and  variety  of  its  eruptive  elements, 


568  MORROW — LEPROSY. 

the  cutaneous  manifestations  of  leprosy  most  accuratel}'  imitate 
many  of  the  ordinary  dermatoses.  This  imitation  is  carried  into  the 
realm  of  neuropathology,  nerve  leprosy  simulating  most  decej)- 
tively  the  manifold  forms  of  neuritis  of  toxic,  traumatic,  and  con- 
stitutional origin. 

The  earh-  manifestations  of  leprosy,  unlike  those  of  syphilis,  are 
in  no  sense  peculiar  to  the  leprous  process.  There  is  nothing  regular 
in  their  mode  of  evolution,  nothing  constant  in  their  appearance, 
nothing  distinctive  in  their  morjihological  characters.  They  are  so 
variable,  uncharacteristic,  and  absolutely  indefinite  that  they  would 
never  be  ascribed  to  leprosj'  in  any  country  where  the  disease  was 
not  endemic,  or  where  there  were  not  decided  reasons  for  suspecting 
its  presence.  This  emphasizes  what  may  be  considered  a  point  of 
cardinal  importance  in  the  diagnosis  of  leprosy.  Since  leprosy  is 
exclusively  human  in  its  origin,  the  history  of  known  contact  with  a 
leper  or  residence  in  a  leprous  country  is  of  the  greatest  diagnostic 
worth. 

Obvioush'  enough  the  difficulties  of  diagnosis  are  increased  in 
non-leprous  countries  where  an  opinion  must  be  based  upon  the 
objective  characters  alone  and  where  the  absence  of  a  history  of 
known  exposure  withholds  the  necessary  confirmation  of  its  correct- 
ness. This  fact  has  been  forcibly  impressed  upon  me  in  the  case  of 
the  patient  pictured  in  Fig.  11,  in  which  there  was  no  clear  history  of 
exposure.  The  attending  physician,  Dr.  MacDougall,  in  sending  the 
additional  notes  of  the  case,  remarks :  "  In  connection  with  the  diag- 
nosis of  these  cases  I  am  inclined  to  believe  that  some  censure  is  due 
leprologists  for  their  positive  statements  that  the  manifestations  of 
the  disease,  when  at  all  advanced,  are  so  characteristic  that  there  can 
be  no  mistake." 

Incidentally  it  may  be  said  that  a  picture  of  these  patients  was  sub- 
mitted to  a  number  of  si^ecialists  in  skin  diseases,  none  of  whom 
would  admit  the  diagnosis  of  leprosy  because  there  was  no  clear  his- 
tory of  exposure,  and  yet  if  they  had  lived  in  a  lej^rous  country  there 
could  have  been  little  doubt  as  to  the  nature  of  the  trouble. 

Erasmus  Wilson  cites  a  case  of  a  medical  man  in  the  Indian  army, 
himself  a  leper,  but  who  with  other  medical  men  in  India  regarded 
his  case  as  syphilis.  A  case  of  Hutchinson  was  treated  for  several 
years  for  rheumatic  gout.  The  man  had  j)ricking  pains  in  the  fingers, 
as  well  as  numbness  and  insensibility,  and  was  unable  to  write. 
Another  of  Hutchinson's  patients  was  treated  for  two  years  by  nerve 
specialists  for  paralysis  affecting  the  ulnar  nerve. 

Thin  cites  numerous  examples  of  cases  erroneously  diagnosed 
by   observers    experienced  in  dermatology;     for  example,    that  of 


DIAGNOSIS.  559 

a  patient  with  a  well-developed  nerve  leprosy,  wlio  was  sent  liome 
from  India  as  a  case  of  lupus  erythematosus;  two  other  cases  in 
which  typical  anaesthetic  patches  with  pigmentary  changes  were 
wrongly  diagnosticated. 

A  case  of  Abraham  was  for  a  long  time  confounded  with  carcinoma. 

Instances  might  be  multiplied  of  cases  of  leprosy  which  exhibited 
sensory  and  even  advanced  trophic  changes,  the  nature  of  which  was 
unrecognized.  A  patient  of  mine  was  for  several  months  under  the 
care  of  one  of  the  most  distinguished  leprologists  of  Europe  without 
his  suspecting  the  nature  of  the  disease,  until  his  perceptions  were 
quickened  by  accidentally  learning  of  the  patient's  former  residence 
in  a  leprous  country. 

Mistakes  in  diagnosis  are  by  no  means  confined  to  physicians  in 
non-leprous  countries.  Even  so  competent  a  clinician  as  Beaven 
Rake,  whose  long  residence  in  Trinidad  made  him  familiar  with  every 
possible  feature  of  the  disease,  reports  a  case  in  which  leprosy  was  by 
him  mistaken  for  syphilis,  an  error  which  was  confirmed  by  the  tem- 
porary disappearance  of  the  tubercles  under  mercury,  but  which  was 
connected  by  the  subsequent  redevelopment  of  the  tubercles  with  other 
unmistakable  signs  of  leprosy. 

In  attending  numerous  examinations  of  persons  arrested  as  lepers 
in  the  Hawaiian  Islands  and  sent  to  Honolulu  to  be  examined  by  the 
examining  board,  I  was  impressed  by  the  large  proportion  of  cases 
placed  in  the  category  of  "  suspects,"  embracing  those  presenting  sus- 
picious symptoms,  but  in  whom  evidences  of  the  disease  were  not 
sufficiently  clear  and  unequivocal  to  warrant  their  consignment  to  the 
leper  settlement  of  Molokai.  Although  the  examining  board  was 
made  up  of  physicians  presumably  familiar  with  every  phase  of  the 
disease  and  who  were  especially  selected  for  their  diagnostic  ability, 
there  was  in  many  cases  much  confusion  as  to  the  nature  of  the  erup- 
tion, especially  when  in  the  early  erythematous  stage.  There  is  no 
doubt  that  it  requires  a  nice  judgment  and  a  thorough  acquaintance 
with  the  incipient  evidences  of  the  disease  to  discriminate  between 
leprous  macules  and  an  erythematous  eruption  due  to  other  causes. 
Notwithstanding  the  precautions  taken  to  avoid  an  erroneous  diag- 
nosis it  frequently  happened  that  persons  were  wrongly  declared 
lepers,  and  in  order  to  rectify  possibly  unjust  sentences  a  medical 
commission  was  appointed  by  the  board  of  health  to  visit  the  leper 
settlement  at  stated  intervals  and  reexamine  persons  enrolled  on  the 
list  of  lepers  who  claimed  that  they  did  not  have  the  disease. 


560  MORROW — LEPROSY. 


Tubercular  Form. 

The  prodromal  symptoms  which  precede  the  eruptive  stage  of  the 
tubercular  form  possess  but  little  diagnostic  value.  Similar  symp- 
toms may  be  present  in  the  secondary  incubation  of  syphilis  or  other 
infectious  diseases.  The  initial  pyrexial  symptoms  present  nothing 
distinctive.  The  attacks  of  fever  succeeded  by  profuse  perspiration 
are  frequently  mistaken  for  ague.  If  the  fever  be  followed  by  an 
erythematous  eruption  which  tends  to  become  j&xed,  suspicion  should 
be  excited,  especially  in  a  country  where  leprosy  is  prevalent.  The 
significance  of  other  prodromal  symptoms,  as  epistaxis,  cephalalgia, 
general  malaise,  etc.,  is  seldom  recognized  until  objective  signs  of  the 
disease  are  manifest,  and  then  they  are,  of  course,  valuable  as  a  retro- 
apective  aid  in  diagnosis.  The  sensory  disorders  which  form  so  val- 
uable an  element  in  the  diagnosis  of  anaesthetic  leprosy  frequently  fail 
in  the  tubercular  form,  and  their  presence  or  absence  may  be  disre- 
garded. Among  the  diseases  with  which  the  tubercular  form  of  lep- 
rosy may  be  confounded  are  certain  dermatoses  of  the  erythematous 
type,  various  pigmentary  afi'ections  of  the  skin,  acne  indurata  and 
rosacea,  sycosis,  erythema  nodosum,  moUuscum,  psoriasis,  syphilis, 
lupus,  mycosis  fuugoides,  etc. 

Erythema.  — The  macular  lesions  which  ordinarily  constitute  the 
first  cutaneous  manifestations  of  leprosy  present  nothing  absolutely 
distinctive  either  in  their  objective  characters  or  course.  Leprous 
roseola  at  its  first  apjiearance  may  be  mistaken  for  a  variety  of  simi:)le 
erythematous  eruptions.  Lailler,  one  of  the  most  experienced  French 
dermatologists,  says  that  he  has  mistaken  a  case  of  leprous  erythema 
for  the  erythema  produced  by  the  ingestion  of  strawberries.  The 
error  was  cleared  up  only  by  the  persistence  of  the  eruption. 

The  §xanthem  sometimes  resembles  that  of  the  eruptive  fevers.  I 
have  recenth^  seen»a  case  in  which  the  initial  rash  had  been  diagnos- 
ticated as  measles,  from  which  it  was  differentiated  by  its  persistence. 
During  three  years  it  faded  and  reappeared  a  number  of  times  in  the 
form  of  erythemato-papular  lesions  before  the  characteristic  tubercu- 
lation  took  place. 

Chronic  dermatitis  is  distinguished  from  leprosy  by  the  more  gen- 
eral and  uniform  thickening  of  the  skin  and  the  absence  of  tubercles. 

Parasitic  Affections. — Ringworm  and  chromophytosis  may  be  mis- 
taken for  leprous  spots.  In  tropical  countries,  as  in  Hawaii,  para- 
sitic skin  affections  often  exhibit  a  luxuriant  development  i^nknown  iu 
cold  or  in  temperate  climates.  Not  infrequently  parasitic  diseases 
coexist  with  leprosy  and  may  mask  the  manifestations  of  the  latter 


DIAGNOSIS.  561 

disease.  An  examination  of  the  scales  and  scrapings  will  always 
identify  tlie  parasites  if  present. 

Acne  Indurata  and  Rosacea. — Hebra  instances  cases  in  whicli  lep- 
rosy has  been  mistaken  for  these  forms  of  skin  affection.  Impey,  who 
has  had  large  opportunities  of  studying  the  clinical  aspects  of  leprosy 
in  South  Africa,  says :  "  I  know  of  no  other  disease  which  may  be  so 
readily  mistaken  for  leprosy  as  rosacea. "  The  eruption  of  gutta  rosea 
is  to  be  distinguished  by  its  localization  on  the  chin,  cheeks,  and  nose 
and  the  exemption  of  the  eyebrows.  In  rosacea  there  is  a  more  uni- 
form thickening  of  the  skin  over  a  large  area — the  color  of  the  erup- 
tion is  more  uniform  than  in  leprous  erythema,  the  hairs  are  not  lost, 
and  the  scales  are  more  abundant.  In  leprous  erythema  there  are  no 
enlarged  vessels  to  be  seen,  the  color  of  the  patch  is  of  a  darker  hue 
in  the  centre  and  gradually  fades  into  the  surrounding  skin,  the  hairs 
are  soon  lost  from  the  leprous  patch. 

Sycosis  is  another  affection  of  the  face  for  which  leprosy  may  be 
mistaken  when  the  tubercles  are  limited  to  the  hairy  parts  of  the  face. 

Liclien  Planus. — When  the  neoplasms  are  small,  flattened,  and 
closely  aggregated  tubercular  leprosy  has  been  confounded  with  lichen 
planus. 

Molluscum  Fibrosum. — One  of  my  colleagues  in  New  York  ex- 
hibited a  case  in  which  leprous  nodules  had  been  mistaken  for  the 
tumors  of  molluscum. 

Keloid  has  been  confounded  with  leprosy.  It  is  to  be  distinguished 
by  its  hard,  fibrous  base,  its  resemblance  to  a  cicatrix,  and  other  ob- 
jective characters,  besides  being  commonly  unilateral. 

Erythema  Nodosum.— \^\ien  the  nodules  are  situated  along  the  ex- 
ternal malleolus  and  the  front  of  the  leg,  they  bear  a  most  deceptive 
resemblance  to  the  nodules  of  erythema  nodosum.  Leloir  mentions 
cases  in  which  the  size,  shape,  and  disposition  of  the  lepromata  were 
strikingly  suggestive  of  this  disease.  The  more  or  less  rapid  involu- 
tionary  changes  of  the  nodules  in  the  latter  disease  would,  of  course, 
soon  clear  up  the  diagnosis. 

Psoriasis  was  at  one  time  considered  a  form  of  leprosy.  It  may 
be  admitted  that  there  was  perhaps  a  superficial  basis  for  this  erro- 
neous view  in  the  objective  resemblance  between  psoriasis  gyrata  and 
the  circinate  lesions  of  leprosy.  The  tendency  of  psoriatic  patches 
to  enlarge  peripherally  and  form  by  their  confluence  circular  and 
gyrate  forms  gives  them  a  configuration  not  unlike  the  circinate  and 
concentric  bands,  especially  seen  in  the  anaesthetic  form  of  the  disease. 
Circinate  psoriasis  is,  however,  readily  differentiated  by  its  tendency 
to  epidermic  proliferation  in  white  or  grayish  scales,  distinctly  imbri- 
cated, which,  when  removed,  show  a  well-defined  infiltration  elevated 
Vol.  XVIII.— 36 


562  MORROW — LEPROSY. 

at  the  border,  depressed  in  the  centre,  with  a  hypersemic,  readily 
bleeding  surface.  From  the  exceeding  commonness  of  psoriasis  in  all 
countries  and  in  all  ages,  it  is  evident  that  sufferers  from  this  disease 
must  have  figured  largely  in  the  population  of  leper  houses. 

Syphilis. — The  old  view  that  "syphilis  was  the  daughter  of  lep- 
rosy," which  was  based  ui)on  the  fact  that  an  ei)idenuc  of  syi^hilis 
made  its  appearance  at  a  period  corresponding  to  tlie  decline  of 
leprosy  in  Europe,  has  been  long  exploded.  We  now  recognize  that 
the  relation  was  coincidental  rather  than  causal,  and  that  each  is  a 
disease  sui  generis.  That  they  are  totally  unrelated  to  each  other  is 
proven  by  the  independent  development  and  coexistence  of  the  two 
morbid  states  in  the  same  j:>atient,  each  running  its  own  course. 
That  "  leprosy  is  more  common  in  the  children  of  syphilitic  parents," 
as  has  been  maintained  by  many  authorities,  may  be  admitted  on  the 
ground  that  a  native  debilit}'  in  the  offspring  of  syphilitics,  like  any 
other  ancestral  cause  of  weakening,  may  predispose  to  leprosy. 

Syphilis  presents  many  clinical  analogies  with  leprosy,  both  in  the 
polymorphous  character  of  its  manifestations  and  their  mode  of  evo- 
lution. In  both,  the  general  accidents  develop  after  a  i)rolonged 
period  of  incubation.  Syphilitic  roseola  has  its  analogue  in  leprous 
erythema ;  syphilitic  pigmentation  in  the  pigment  spots  of  leprosy ; 
syphilitic  alopecia  in  the  alopecia  of  leprosy.  The  papules  and  tu- 
bercles of  syphilis  have  their  counterpart  in  the  dermic  and  hypoder- 
mic nodules  of  leprosy.  In  both,  the  neoplasms  follow  a  similar 
course  of  involution ;  they  maj^  undergo  resorption,  or  they  may  soften 
and  suppurate  and  disappear  by  a  process  of  ulceration,  sometimes 
involving  extensive  surfaces  and  leaving  characteristic  cicatrices. 
Their  points  of  dissimilarity  are,  however,  too  numerous  and  obvious 
to  merit  mention. 

The  erythematous  syphilide  maj-  be  distinguished  from  leprous 
erythema  by  the  smaller  size  and  fainter  coloration  of  the  lesions, 
their  absence  from  the  face  and  limitation  to  i^arts  habitually  covered 
by  the  clothing,  and  their  more  rapid  disappearance.  The  er3'them- 
atous  patches  of  leprosy  are  larger,  more  diffuse,  and  more  perma- 
nent. The  pigmentations  of  leprosy  are  readily  distinguished  from 
the  posthumous  iDigmentations  of  syphilitic  infiltrations.  The  len- 
ticular tubercles  of  leprosy,  when  they  are  disseminate,  small,  slighth' 
elevated,  with  moderate  desquamation,  may  resemble  absolutely  a 
papular  syphiloderm.  It  is,  however,  the  tubercular  form  of  syphilis 
which  bears  the  most  deceptive  resemblance  to  leprosy. 

The  clinical  features  of  the  case  of  tubercular  leprosy  represented  in 
Fig.  3,  are  seen  to  simulate  almost  accurately  a  tubercular  syphilide. 
The  syphilitic  nodules  are  more  circular  in  outline,  more  reddish- 


DIAGNOSIS.  *       563 

brown  or  coppery  in  color,  more  apt  to  be  grouped  in  circular  and 
crescentic  forms,  and  more  rapid  in  involution.  TLe  ulcerations  of 
sypliilis  are  more  rounded,  less  circumscribed  in  extent,  tlie  crusts 
are  thicker,  liarder,  and  of  a  brownisli,  blackish,  or  greenish  tint. 
Leprous  ulcerations  progress  more  slowly  than  those  of  syphilis,  and 
they  do  not  present  a  serpiginous  mode  of  extension.  The  extensive 
superficial  infiltrations  of  leprosy  are  not  seen  in  syphilis.  Leprous 
neoplasms  are  larger  in  volume,  more  protuberant,  and  crowded  upon 
an  infiltrated  base,  with  oedema  of  the  skin  and  ganglionic  enlarge- 
ments. Their  seats  of  predilection  are  the  facial  mask,  the  lobes  of 
the  ears,  backs  of  the  hands,  and  forearms,  more  rarely  disseminated, 
while  the  nodules  of  syphilis  are  indiscriminate  in  their  location  and 
may  come  where  leprous  tubercles  rarely  or  never  appes.r.  The  leon- 
tiasis  of  leprosy  is  much  more  pronounced  than  that  of  sj' philis.  The 
enormous  nodular  masses,  the  deep  orbital  and  supraorbital  furrows, 
the  pillowy-like  protuberances  of  the  cheeks,  with  loss  of  the  eye- 
brows, are  never  observed  in  syphilis.  Still,  in  many  cases  of  less 
exaggerated  development  the  facies  of  leprosy  may  simulate  most 
closely  that  of  syphilis. 

Lupus  Vulgaris. — This  form  of  cutaneous  tuberculosis  shares  with 
leprosy  the  j^athological  peculiarities  of  cell  infiltration  of  the  connec- 
tive tissues  of  the  skin,  followed  by  disintegration  of  the  morbid 
products  and  ulceration.  Leprosy  maj'  be  mistaken  for  lupus  vul- 
garis, especially  when  the  leprous  lesions  consist  of  small  brownish- 
red  tubercles  grouped  upon  a  reddened  infiltrated  base  and  localized 
upon  the  cheeks  and  face ;  the  frequent  involvement  of  the  lobe  of  the 
ear  in  lupus  heightens  the  similitude.  Lupus  is  distinguished  b}^  its 
occurrence  in  the  form  of  isolated  patches  and  its  more  limited  locali- 
zation; it  is  commonly  unilateral  and  not  accompanied  by  disorders 
of  sensation.  In  all  doubtful  cases  of  tubercular  leprosy  the  demon- 
strable presence  of  the  bacilli  in  the  tissues  or  liquid  exudates  estab- 
lishes the  diagnosis. 

Lupus  erythematosus  may  also  be  mistaken  for  leprosy.  I  have 
been  consulted  by  a  leprous  patient,  the  right  side  of  whose  forehead 
and  cheek  was  occupied  by  slightly  raised  erythematous  patches  of  a 
sombre  red  color  simulating  perfectly  lupus  erythematosus.  The  lat- 
ter disease  may  be  usually  distinguished  by  the  configuration  of  the 
patches  which  often  assume  a  butterfly  shape,  by  the  central  depres- 
sion of  the  plaque  and  the  greasy  adherent  scales  which  often  dip  down 
into  the  follicles,  and  by  its  limitation,  as  a  rule,  to  the  face. 

Blycosis  Fangoides. ^On  account  of  the  numerous  and  marked 
analogies  between  this  disease  and  leprosy  in  their  evolutionary  mode 
and  the  objective  character  of  their  phenomena,  mycosis  fungoides 


564      *  MORROW — LEPROSY. 

has  been  not  inaptly  designated  by  Bazin  as  indigenous  leprosy.  Both 
diseases  are  characterized  by  an  eruption  of  erythematous  spots  or 
patches,  which  may  appear  and  recede  a  number  of  times  before  be- 
coming permanent.  These  patches  are  the  seat  of  the  neoplastic  for- 
mations i)eculiar  to  each  disease. 

In  the  premycosic  stage  the  efflorescences  are  at  first  transitory,  but 
they  grow  more  and  more  persistent  until  they  become  permanently 
established  under  the  form  of  reddish,  slightly  scaly,  or  lichenoid 
plaques.  After  the  lapse  of  time  more  or  less  variable  these  plaques 
become  the  seat  of  red  or  violaceous  tumors,  isolated  or  grouped, 
which  may  remain  stationary,  undergo  involution  by  a  process  of 
resorption  and  become  effaced  without  leaving  a  trace,  or  break 
down  and  become  fungous  and  ulcerating.  A  further  similitude  to 
leprosy  may  be  noted  in  the  sensory  disorders  which  are  frequently 
manifest.  The  surface  sensibility  is  sometimes  markedly  diminished, 
the  hairs  may  become  atrophied  and  disappear ;  the  lymphatic  glands 
become  tumefied  and  swollen.  Both  diseases  almost  invariably  pro- 
gress to  a  fatal  termination.  The  resemblance  to  leprosy  is  most 
marked  when  the  lesions  of  mycosis  are  localized  upon  the  face.  As 
differential  jooints  may  be  mentioned  the  constant  and  intolerable 
pruritus  of  mycosis,  which  is  almost  invariably  present.  In  the 
tumor  stage  the  soft,  dough-like  masses  with  their  fungating,  tomato- 
like ax)pearance  present  a  picture  unlike  that  of  leprosy.  The  pres- 
ence or  absence  of  the  bacillus  leprae  will  set  aside  all  doubt  as  to  the 
diagnosis. 

31uUipIe  sarcomata  have  been  mistaken  for  leprosy.  The  develop- 
ment of  these  tumors  is  rarely  preceded  by  the  appearance  of  ery- 
thematous patches,  and  their  localization  is  different. 

Alopecia. — The  alopecia  of  leprosy  is  characterized  by  the  atrophy 
and  disappearance  of  the  eyebrows  and  lashes,  the  vibrissse,  and  the 
hairs  from  other  portions  of  the  body  the  seat  of  leprous  lesions, 
while  the  hair  of  the  scalp  is  not  much  affected. 

Leprosy  op  the  Mucuous  Membranes. 

A  new  and  unique  interest  has  been  given  to  the  diagnosis  of  lep- 
rosy of  the  nasal  mucous  membranes  owing  to  the  now  generally 
recognized  precocity  of  their  appearance.  Leprosy  in  the  early  stage 
often  simulates  catarrhal  inflammation  of  the  nose.  Since  leprous 
rhinitis  is  dependent  upon  the  presence  and  local  action  of  the  bacilli 
upon  the  Schneiderian  membrane,  the  diagnosis  may  be  established 
by  bacteriological  examination  of  the  nasal  secretions  which,  espe- 
cially in  the  tubercular  form,  contain  them  in  large  numbers.     Epi- 


DIAGNOSIS.  565 

staxis  is  a  more  constant  accompaniment  of  tlie  leprous  process  than 
of  an  ordinary  rhinitis. 

The  diseases  affecting  the  mucous  membranes  of  the  mouth,  nose, 
and  throat  which  may  be  confounded  with  leprosy  in  a  more  advanced 
stage  are  few.  They  all  belong  to  infectious  diseases  of  the  granu- 
loma type,  and  while  offering  a  great  similarity  of  aspect,  they  are 
distinguished  by  certain  special  characters. 

Syphilis. — Syphilitic  infiltrations  of  the  nasal  mucous  membranes 
bear  a  deceptive  resemblance  to  those  of  leprosy.  They  affect  the 
framework  of  the  nose  and  are  often  followed  by  extensive  destruc- 
tion of  the  tissues  and  resulting  deformities.  S^^philis  is,  however, 
more  liable  to  attack  the  osseous  framework  of  the  nose,  producing  a 
sinking  in  or  falling  of  the  bridge  of  the  nose.  The  deformation  of 
the  nose  in  leprosy  is  commonly  due  to  a  destruction  of  the  cartilag- 
inous septum  which  leads  to  flattening  and  broadening  of  the  alse, 
which  fall  and  become  spread  out  from  the  loss  of  natural  support. 
Syphilis  may  also  occasion  destruction  of  the  septum. 

A  rhinoscopic  examination  of  the  leprous  nose  in  the  tubercular 
form  will  reveal  the  presence  of  small  tubercles  disseminated  upon 
the  septum,  sometimes  over  the  turbinated  bones,  with  ulceration. 
The  presence  of  anaesthesia  also  serves  to  indicate  the  leprous  nature 
of  the  changes. 

The  syphilitic  affections  of  the  tongue,  the  buccopharyngeal  cav- 
ity, and  the  larynx  often  bear  a  deceptive  resemblance  to  those  of 
leprosy.  Leloir  has  called  attention  to  the  occurrence  of  forms  of 
leprous  glossitis  which  recall  similarly  appearing  sclerogummatous 
infiltrations  of  syphilis. 

Leprosy  of  the  mouth  and  throat  exhibits  in  the  localization  and 
size  of  the  tubercles,  which  are  usually  small  and  disseminate,  certain 
objective  characters  not  seen  in  syphilis.  The  ulcerations  of  syphilis 
are  more  profound  and  extensively  destructive  and  the  ulcerative  proc- 
ess is  more  acute.  The  complete  abolition  of  ordinary  sensibility 
and  the  conservation  of  the  sense  of  taste  in  its  integrity  are  charac- 
teristic of  the  leprous  process. 

Lupus  produces  alterations  of  the  nose  quite  different  from  those 
occurring  in  leprosy.  Lupus  exhibits  a  marked  tendency  to  implica- 
tion of  the  soft  tissues  with  more  or  less  infiltration  and  sclerosis. 
The  alas  of  the  nose  are  nibbled  by  ulcerations,  and  the  nose  itself  is 
shortened  and  thinned,  contrasting  with  the  nose  en  Im^gnette  of  lep- 
rosy. Even  when  lupus  destroys  the  septum,  the  sclerosed  tissues 
support  the  structure  and  prevent  the  falling  and  flattening  observed 
in  leprosy.  Besides,  the  lupous  process  is  more  chronic  and  persist- 
ent in  its  morbid  pertinacity,  rarely  relaxing  its  work  until  the  cu- 


566  MORROW — LEPROSY. 

taneous  covering  of  the  cartilaginous  segment  of  tlie  nose  is  entirely 
destroye'd. 

Glanders,  which  is  comparatively  rare  in  the  human  subject,  may 
also  simulate  leprosy  of  the  mucous  membranes  in  the  production  of 
small  barley-  to  pea-sized  tubercles,  isolated  or  confluent  and  dissemi- 
nated over  the  cartilaginous  septum  and  the  turbinated  bones.  These 
may  break  down  and  ulcerate  with  the  production  of  a  purulent  or 
mucopurulent  secretion.  Similar  processes  may  also  affect  the  mu- 
cous membranes  of  the  eye,  the  mouth,  and  the  throat.  Glanders 
may  always  be  identified  by  the  presence  of  the  bacillus  mallei,  which 
is  readily  inoculable  to  animals. 

In  the  differentiation  of  leprosy  from  the  above  group  of  diseases, 
the  history,  the  concomitant  evidences  of  skin  trouble  peculiar  to 
each  disease,  and  the  presence  or  absence  of  anaesthesia,  which  is 
pathognomonic  of  leprosy,  are  usually  quite  sufficient,  independent  of 
a  bacteriological  examination  of  the  secretions. 

In  addition  the  obstruction  of  the  nostrils,  the  harsh,  raucous,  or 
croaking  voice  of  leprosy,  the  difficulties  of  deglutition  and  respira- 
tion, and  the  jieculiar,  foul  leprous  odor  exhaled  by  the  breath  are 
all  characteristic  features. 

The  Anesthetic  Form. 

The  prodromal  symptoms  are  much  more  variable,  but  scarcely 
more  characteristic  than  those  of  the  tubercular  form.  The  sen- 
sory disorders,  hyperaesthesia,  formication,  pruritus,  and  sensations 
of  burning  and  tingling,  have  little  diagnostic  value,  as  they  may  be 
present  in  irritative  neuritis  from  other  causes.  The  pain  and  motor 
weakness  often  present  are  commonly  ascribed  to  rheumatism  or  neu- 
ralgia. At  a  more  advanced  stage  the  presence  of  anassthesia  consti- 
tutes an  almost  invaluable  diagnostic  element  as  the  identification  of 
the  bacillus  in  the  tissues  is  rarely  practicable  in  nerve  lepros3\ 

The  erythematous  spots  of  the  anaesthetic  form  are  characterized 
by  their  permanence,  their  tendency  to  clear  in  the  centre  while  spread- 
ing peripherally,  their  achromatic  changes,  and  at  a  more  advanced 
period  by  their  anaesthetic  centres. 

Chromophytosis.- — The  pigmented  spots  may  be  yellowish  or  fawn 
colored,  giving  quite  a  deceptive  resemblance  to  chromophytosis. 
The  patches  of  the  latter  are  furfuraceous  and  may  readily  be  removed. 

EpheJides. — In  one  of  Hutchinson's  cases  the  first  S3^mi)toms  were 
large  freckles  on  the  forehead,  followed  by  a  general  exanthem  and 
dulled  sensation. 

Chloasma  has  been  confounded  with  the  pigmented   patches   of 


DIAGNOSIS.  567 

leprosy.     Quite  recently  a  case  came  under  my  observation  in  wliieli 
tMs  mistake  had- been  made. 

Pellagra,  acrodynia,  and  chronic  ergotism  may  be  mistaken  for  tke 
pigmentations  of  leprosy.  In  pellagra  the  brownisb-red,  erythem- 
atous patches,  the  appearance  of  bullae,  the  atrophic  changes,  and 
paralysis  of  the  third  nerve  make  up  a  clinical  picture  which  bears  a 
most  deceptive  resemblance  to  certain  phases  of  leprosy. 

Scleroderma  and  sclerodaciylie ,  that  form  of  the  affection  in 
which  the  atrophic  troubles  are  limited  to  the  extremities,  may  be 
confounded  with  leprosy.  Scleroderma  is  characterized  by  indu- 
ration followed  by  atrophy  of  circumscribed  portions  of  the  skin 
which  are  more  or  less  diffused  and  symmetrical.  The  patches  are 
white,  often  of  a  yellow  or  old-ivory  color,  the  secretions  of  the  seba- 
ceous and  sudatory  glands  are  diminished,  as  in  leprosy,  and  the  sen- 
sibility is  first  increased  and  then  diminished.  Subcutaneous  tuber- 
cles have  been  observed  in  a  few  cases.  The  objective  differences 
between  leprosy  and  this  form  of  the  disease  are  so  marked  as  scarcely 
to  permit  of  the  possibility  of  a  mistake  in  diagnosis. 

The  trophic  changes  met  with  in  sclerodaciylie,  characterized  by 
distortion  of  the  phalanges,  alterations  of  the  nails,  and  the  ulcera- 
tions which  are  not  uncommon,  present  a  much  greater  similitude 
with  leprosy.  They  are  to  be  differentiated  by  the  absence  of  the 
concomitant  signs  of  leprosy. 

Morplioea. — Erasmus  Wilson  describes  morphoea  alba,  lardacea, 
and  nigra  as  forms  of  local  leprosy.  Kaposi  has  followed  his  exam- 
ple in  identifying  these  varieties  of  morphoea  with  macular  leprosy. 
While  morphoea  may  present  a  certain  resemblance  in  color,  form, 
and  distribution  with  the  sclerotic  patches  of  leprosy,  yet  it  is  readily 
diff'erentiated.  The  plaques  of  morphoea  are  lardaceous  or  wax-white 
in  appearance,  of  a  hard,  unyielding  consistence,  and  surrounded 
with  a  violet  or  lilac  ring  which  is  most  characteristic,  and  in  addi- 
tion the  sensory  disorders  of  leprosy  are  absent.  Some  three  years 
ago  a  case  of  morphoea  came  under  my  observation  which  had  been 
diagnosticated  by  a  number  of  physicians  as  indigenous  leprosy. 

Vitiligo. — The  achromatic  spots  of  nerve  leprosy  may  be  mistaken 
for  vitiligo.  The  patches  of  vitiligo  are  of  an  irregular  shape,  of  a  dead- 
white  color,  perfectly  smooth  surface,  and  with  margins  convex  and 
clearly  defined  against  the  surrounding  pigmented  border,  which  has 
a  tendency  to  spread  peripherally.  With  the  exception  of  the  dys- 
chromia the  skin  is  unaltered  in  structure  and  the  sensibility  is  un- 
changed ;  the  hairs  of  the  affected  surface  are  often  white,  but  do  not 
fall.  In  leprous  leucoderma,  which  is  most  often  seen  in  dark  races, 
the  spots  are  grayish-white  and  not  so  sharply  defined  in  contour. 


568  MORROW — LEPROSY. 

The  skin  is  altered  iu  structure  with  atrophy  of  its  glandular  appa- 
ratus, atroj)hic,  depressed,  sometimes  corrugated,  and  commonly  com- 
pletely anaesthetic.  The  hairs  are  not  invariably  white  and  often  fall 
from  the  patch.  The  evolutionary  mode  is  entirely  different.  While 
the  leprous  achromatic  spots  may  appear  as  such  from  the  first,  they 
are  ordinarily  formed  by  a  pigmented  patch  becoming  white  in  the 
centre  with  coincident  loss  of  sensation. 

Femjjhigus  Vulgaris. — The  pemphigus  blebs  which  characterize 
nerve  leprosy  may  be  mistaken  for  pemphigus  vulgaris.  The  bullae 
of  leprosy  may  be  distinguished  by  their  sparser  numbers,  their  more 
superficial  characters,  their  localization,  their  tendency  to  come  out 
in  successive  crops,  their  characteristic  cicatrices  Avhen  they  become 
ulcerated,  and  by  the  sensory  disorders  which  ordinarily  accompany 
or  succeed  them. 

In  many  cases  leprosy  pursues  an  anomalous  course.  The  macu- 
lar, pemphigoid,  and  other  trophic  changes  may  be  absent,  and  motor 
and  sensory  disturbances  constitute  the  only  manifestations.  There 
are  many  diseases  depending  upon  lesions  of  the  peripheral  nerves 
and  cord  the  symjitoms  of  which  may  be  accurately  simulated  by 
leprosy.  When  these  neuritic  changes  are  accompanied  by  tlie  pres- 
ence or  history  of  leprous  exanthems,  or  phenomena  of  hyperesthesia 
and  anaesthesia,  swelling  of  the  nerves,  disturbances  of  the  sweat  func- 
tion, leprous  coryza,  etc. ,  there  is  no  difficulty  in  diagnosis ;  but  when 
such  concomitant  evidences  fail,  and  the  paralytic  and  atrophic 
changes  constitute  the  sole  objective  signs,  remaining  stationary  and 
persisting  for  months  or  years,  the  diagnosis  may  become  exceedingly 
difficult. 

The  phenomena  of  leprous  neuritis  constitute  a  distinctive  feature 
of  great  diagnostic  importance.  The  ulnar  nerves  are  usually  pri- 
marily involved,  but  not  invariably,  as  affections  of  the  nerves  of  the 
legs  may  be  first  manifest.  In  many  cases  patients  complain  of 
numbness  and  weakness  in  the  muscles  of  the  foot  and  extensors  of 
the  toes,  which  are  due  to  beginning  atrophy  of  the  peronei  and  ex- 
tensors. In  the  majority  of  cases  the  ulnars  are  the  first  to  manifest 
evidences  of  inflammatory  and  degenerative  changes  accompanied 
by  the  atrophic  changes  in  the  hands  and  forearms  already  described. 

The  paralysis  may  in  some  cases  appear  first  in  the  orbicularis 
palpebrarum  and  other  muscles  supplied  by  the  cranial  nerves,  render- 
ing it  impossible  to  close  the  eyes,  or  the  face  may  be  drawn  to  one 
side. 

Progressive  muscular  atrophy  may  be  confounded  with  leprosy. 
There  is  the  same  wasting  of  the  interossei,  of  the  thenar  and  hy- 
pothenar  muscles,  with  paralysis  of  the  extensors  resulting  in  the  main 


DIAGNOSIS.  569 

en  griffe  characteristic  of  leprosy,  biit  the  muscular  atrophy  is  differ- 
entiated br  the  absence  of  anaesthetic  patches  and  thickening  of 
the  nerves. 

Paralysis  agitans  is  another  affection  for  which  leprosy  has  been 
mistaken.  Impey  mentions  a  case  he  found  in  the  leper  ward  of  this 
form  of  paralysis.  The  patient  was  unable  to  walk  or  even  leave 
her  chair.  Constant  friction  had  caused  extensive  ulceration  of  one 
foot.  Both  feet  were  much  deformed  and  the  hands  were  contracted 
but  there  were  no  anaesthetic  patches  and  the  eyes  were  unaffected. 

Multiple  neuritis  of  toxic  or  malarial  origin  presents  many  analo- 
gies with  the  earlier  stage  of  anaesthetic  leprosy,  but  is  distinguished 
by  its  more  acute  course  and  the  absence  of  anaesthetic  patches. 

Arthritis  Defonnans. — The  characteristic  deformities  of  the  hands 
and  feet  caused  by  chronic  rheumatism  have  been  confounded  with 
those  of  leprosy.  This  mistake  is  all  the  more  liable  to  occur  as  the 
muscular  pains  and  other  early  phenomena  of  leprosy  are  often  at- 
tributed to  rheumatism.  The  swollen  joints  of  arthritis  do  not  occur 
in  leprosy,  and  there  is  an  absence  of  localized  morbid  deposits,  the 
changes  in  leprosy  being  essentially  atrophic. 

Perforating  Ulcer. — The  plantar  ulcer  of  leprosy  beara  a  most  de- 
ceptive resemblance,  both  in  objective  characters  and  course,  to  the 
mal  perforant,  which  may  be  due  to  atheromatous  changes  or  of  purely 
nervous  origin.  In  the  latter  affection  the  concomitant  symptoms  of 
leprosy  are  absent. 

The  lesions  of  the  bones  and  joints  with  deformities  and  mutila- 
tions which  commonly  occur  in  the  advanced  stage  of  nerve  leprosy 
can  scarcely  be  confounded  with  the  changes  occasioned  by  other  dis- 
eases. Yet  Impey  reports  that  he  found  in  the  Eobben  Island  Asy- 
lum one  patient  who  had  lost  his  toes  from  the  necrosis  of  frostbite; 
another  had  been  sent  there  because  he  had  lost  his  feet  by  gangrene. 
"  The  latter  patient  was  kept  in  the  leper  asylum  for  many  years  with- 
out any  suspicion  having  apparently  been  raised  as  to  the  true  nature 
of  the  disease  or  deformity." 

Syringomyelia. — This  disease,  which  may  no  longer  be  considered 
a  pathological  rarity,  presents  the  closest  clinical  analogies  with  nerve 
leprosy,  and  their  differentiation  may  be  difficult  or  impossible. 
There  is  such  a  striking  similitude  in  their  course  and  symptoms  that 
the  error  of  confounding  them  is  almost  inevitable  in  the  absence  of 
the  prior  manifestations  and  etiological  history  of  leprosy.  Leloir 
and  Dejerine  have  reported  cases  in  which  the  diagnosis  was  extremely 
difficult.  It  is  only  in  the  anaesthetic  period  of  leprosy  that  confusion 
is  likely  to  arise. 

The  more  prominent  and  distinctive  clinical  features  of  syringe- 


570  MORROW— LEPROSY. 

myelia  may  be  thus  summarized.  There  is  an  absence  of  surface  dis- 
colorations  or  characteristic  spots  ou  the  skin ;  a  complete  integrity  of 
the  muscles  of  the  face;  a  conservation  of  the  integrity  of  the  pilous 
system;  a  disassociation  of  the  different  modes  of  sensation;  the 
sensibility  to  pain,  to  heat,  and  cold  is  abolished,  with  integrit}^  of 
the  tactile  sensations.  In  addition  there  is  frequently  a  deviation 
of  the  vertebral  column. 

In  leprosy,  tactile  sensibility  is  most  frequently  abolished ;  there 
are  atrophy  and  paralj^sis  of  the  superficial  muscles  of  the  face ;  dou- 
ble paralysis  of  the  orbicular  muscles ;  thickening  of  the  nerve  trunks, 
especially  the  ulnars,  with  nodular  swellings ;  pigmented  or  achromatic 
patches  which  may  be  anaesthetic,  dystrojihia  of  the  extremities ;  spon- 
taneous loss  of  the  phalanges,  alterations  or  loss  of  the  nails,  and  alo- 
pecia. The  difficult}'  of  diagnosis  is  complicated  by  the  fact  that  it 
is  not  always  possible  to  demonstrate  the  presence  of  the  bacillus  in 
nerve  leprosy. 

While  the  sensory  disorders  in  leprosj-  and  syringomyelia  present 
numerous  points  of  resemblance,  their  distinctive  characters  have 
been  thus  differentiated  by  Jeanselme : 

"The  anaesthesia  of  leprosy  is  always  symmetric,  at  first  ribbon- 
like, later  segmentary,  imperfecth'  disassociated  and  of  an  intensity 
gradually  decreasing  in  going  from  the  surface  of  the  skin  to  the 
deeper  portions  and  from  the  free  extremity  of  the  limbs  to  their  root. 
The  anaesthesia  of  syringomyelia  is  often  asymmetric,  segmentary 
from  the  first,  in  general  perfectly  disassociated  and  separated  hj  a 
sharp  limitation  of  the  superficial  and  subjacent  sensible  regions. 

Finally  may  be  mentioned  those  atypical  forms  of  the  disease  in 
which  a  deviation  from  the  normal  plan  of  evolution  introduces  an  ele- 
ment of  confusion  in  diagnosis.  While  as  a  rule  the  lesions  of  lep- 
rosy are  more  or  less  syinmetrical,  cases  are  met  with  in  which  the 
manifestations  are  strictly  unilateral.  I  have  had  under  observation 
a  case  in  which  twelve  years  after  infection  the  only  symptoms  were 
dystrophia  and  anaesthesia  of  the  right  hand,  forearm,  and  ankle; 
another  of  ten  years'  duration  in  which  the  manifestations  were  lim- 
ited to  three  or  four  erythematous  patches  with  anaesthetic  centres  on 
the  left  side ;  still  another  of  mixed  leprosy  in  which  the  sole  signs  of 
the  disease  were  a  single  tubercle  on  the  right  cheek  and  anaesthetic 
changes  in  the  right  hand. 

Quite  recently  I  have  seen  a  case  in  which  the  erythematous 
patches  were  symmetrical,  but  the  trophic  changes  were  absolutely 
unilateral  and  limited  to  complete  disorganization  of  the  right  ulnar 
nerve,  the  parts  supplied  by  which  were  insensitive  to  pressure, 
atrophied,  and  wasted,  and  there  was  a  characteristic  claw-like  defor- 


PEOGNOSIS.  571 

mation  of  the  right  hand.  The  left  ulnar  nerve  was  apparently 
normal,  and  the  muscles  of  the  left  hand  and  arm  were  unaffected. 
There  was  no  appreciable  involvement  of  the  nerves  or  the  muscles 
of  the  face.     Even  the  eyelashes  were  conserved  in  complete  integrity. 

While  the  cases  seen  in  non-leprous  countries  are  perhaps  more 
apt  to  exhibit  atypical  manifestations,  yet  even  in  countries  where 
leprosy  is  endemic  the  same  peculiarity  is  manifest.  In  the  leper 
settlement  of  Molokai,  according  to  Mr.  Dutton,  "  quite  a  number  of 
cases  would  never  exhibit  to  an  ordinary  observer  any  peculiarit}'^ 
indicating  leprosy  in  more  than  one  or  two  phases,  as  in  a  hand  or 
foot.  Some  ot  these  cases,  what  we  may  term  localized  cases,  remain 
in  much  the  same  state — outwardly  viewed — for  ten  years  or  more." 

From  what  has  been  said,  it  is  evident  that  in  countries  where 
leprosy  is  not  endemic,  but  is  only  occasionally  met  with,  its  diag- 
nosis is  beset  with  greater  difficulties.  In  such  cases  an  incxuiry  into 
the  history  and  antecedents  of  the  patient  may  give  a  clew  to  the 
nature  of  the  suspicious  symptoms.  Possible  exposure,  either  by  con- 
tact with  a  leper  or  by  residence  in  a  country  where  leprosy  prevails, 
is,  of  course,  a  sine  qua  non  of  contagion. 

The  modes  of  infection  in  leprosy  are  so  many  and  mysterious 
that  the  mere  fact  of  residence  in  a  leprous  country,  even  without 
known  contact  with  lepers,  is  sufficient  presumptive  proof  of  conta- 
gious exposure. 

PROGNOSIS. 

The  experience  of  all  ages  is  that  leprosy  is  a  practically  incurable 
disease.  With  rare  exceptions  it  progresses  to  a  fatal  termination. 
The  prognosis  in  a  given  case  is  therefore  unfavorable. 

As  regards  the  more  or  less  rapid  evolution  of  the  disease,  the 
prognosis  is  influenced  by  the  constitutional  vigor  of  the  patient,  ex- 
pressed in  the  power  of  resistance  of  his  tissues  to  the  inroads  of 
the  bacilli,  by  climatic  conditions  and  hygienic  surroundings. 

There  is  no  infectious  disease,  of  a  necessarily  fatal  character, 
that  is  so  protracted  in  its  incubation,  so  mild  in  its  initial  manifesta- 
tions, so  prolonged  in  its  exemption  from  serious  accidents,  and  which 
grants  its  victim  so  long  a  lease  of  life  as  leprosy.  Even  after  the 
characteristic  evidences  of  the  disease  are  manifest,  the  patient  may 
live  in  comparative  health  for  many  years,  with  faculties  unimpaired 
and  capacity  of  usefulness  and  work  practically  undiminished.  This 
is  especially  true  of  nerve  leprosy. 

In  anaesthetic  cases  the  entire  symptomatology,  for  five  or  ten  years, 
or  longer,  may  be  limited  to  a  few  erythematous  patches  and  occa- 
sional  neuritic   pains.     I  have    had    under    my  observation  three 


572  MORROW — LEPROSY. 

patients  with  unmistakable  signs  of  anaesthetic  leprosy,  two  of  twelve 
years'  duration  and  one  of  seven  years.  In  one  case  there  has  been  a 
marked  retrogression  in  the  sj'mptoms  with  apj)arent  cure;  in  the 
other  two  the  symptoms  have  remained  practically  stationary.  It  is  a 
matter  of  common  observation  that  in  countries  where  the  disease  is 
eudemic  its  course  is  much  more  rapid  than  when  the  patient  is  re- 
moved to  a  temperate  climate  where  it  does  not  prevail.  Whether 
the  abatement  is  due  to  the  climate,  the  food,  or  the  changed  habits 
of  living,  there  is  commonly  observed,  for  a  time  at  least,  an  arrest 
or  retrogression  of  the  manifestations.  Unfortunately  this  lull  in  the 
manifestations  is,  as  a  rule,  not  of  long  duration,  and  after  a  tempo- 
rary truce  tha  force  of  the  disease  reasserts  itself  and  the  patient 
finally  succumbs.  Lepers  coming  to  this  country,  for  example,  al- 
most iuvariabl}^  improve,  for  a  time  at  least,  and  the  disease  pursues 
a  milder  and  longer  course. 

As  regards  the  duration  of  life,  the  prognosis  is  much  more  unfa- 
vorable in  the  tubercular  than  in  the  r.nsesthetic  form.  When  there 
is  a  transition  of  one  form  into  another  the  prognosis  is  more  or  less 
favorable,  according  as  the  prominent  symptoms  of  one  or  the  other 
gain  the  ascendency.  As  Leloir  somewhat  paradoxically  johrases  it, 
"  the  worst  that  can  happen  to  a  trophoneurotic  leper  is  to  become  a 
tubercular  leper.  The  best  that  can  happen  to  a  tubercular  leper  is 
to  become  a  trophoneurotic  leper." 

Abortive  Cases. — The  occasional  occurrence  of  a  spontaneous  cure 
of  leprosj'  must  be  considered  in  connection  with  i^rognosis.  There 
is  a  sufficient  number  of  cases  on  record  to  prove  that  the  disease 
may  not  onh'^  be  arrested,  but  that  all  evidences  of  its  active  existence 
may  definitely  disappear.  As  compared  with  the  vast  number  of 
cases  that  end  fatally,  the  abortive  cases  are  few  in  number,  but  in 
every  country  where  leprosy  prevails  we  have  well-authenticated  rec- 
ords of  patients  who  have  shown  characteristic  and  unmistakable 
signs  of  the  disease,  experiencing  a  complete  and  i:)ermanent  cessa- 
tion of  all  manifestations.  This  exemption  has  been  observed  to  con- 
tinue for  ten,  twenty,  thirty  years,  or  longer,  and  the  patients  finallj'  die 
of  some  other  disease.  This  spontaneous  cure  may  take  place  at  any 
period  of  the  disease.  Most  of  the  cases  reported  as  cured  are  ad- 
vanced in  their  evolution,  and  apparently  the  reparative  process  takes 
place  after  more  or  less  damage  to  the  tissues. 

In  a  recent  communication,  Hansen,  of  Bergen,  Norway,  states 
that,  of  the  8,453  lepers  who  have  been  recorded  in  the  leper  statistics 
of  Norway,  from  1856  to  1895  there  are  one  hundred  and  twenty-six 
cases  tabulated  as  being  cured.  Hansen  throws  doubt  upon  the 
authenticity  of  cure  in  some  of  these  cases. 


PROGNOSIS.  573 

Thin  says :  "  If  a  patient  loses  all  symptoms  of  tubercular  leprosy 
and  enjoys  good  health,  but  retains  some  slight  symptoms  of  nerve 
leprosy  of  an  unprogressive  character,  the  case  may  be  considered  as 
much  a  case  of  cure  as  a  case  of  phthisis  in  which  all  symptoms  have 
become  arrested,  although  the  patient  is  left  with  a  patch  of  fibroid 
tissue  in  his  lung,  in  which  doubtless  the  spores  of  tuberculosis  are 
embedded."  Arning  reports  that  he  has  cognizance  of  a  neurosis,  in 
which  the  nerves  were  particularly  affected,  in  which  only  one  or 
more  of  the  usual  symptoms  were  present  and  when  the  condition  of 
the  patient  would  not  have  excited  the  slightest  suspicion  of  leprosy 
in  any  other  than  a  specialist.  Such  he  regards  as  instances  of  abort- 
ive leprosy.  Although  such  cases  are  well  attested,  many  medical 
men,  while  admitting  that  the  disease  is  permanently  arrested,  deny 
that  the  patients  are  cured,  insisting  that  unless  it  can  be  proved  by 
microscopical  examination  that  no  bacilli  exist  in  any  of  the  tissues 
of  the  body  the  case  cannot  be  pronounced  cured. 

Even  cases  conforming  to  this  crucial  test  are  not  wanting.  Hal- 
lopeau  reported  to  the  Berlin  Leprosy  Congress  the  case  of  a  young 
Haytien  who  had  been  affected  with  a  severe  form  of  nerve  leprosy, 
and  who  succumbed  to  a  pulmonary  tuberculosis.  A  most  careful 
bacteriological  examination  practised  by  M.  Jeanselme  after  death 
demonstrated  the  complete  absence  of  bacilli  although  they  had  been 
found  abundantly  some  time  before,  showing  that  the  patient  was 
cured.     There  remained  only  the  secondary  stigmata  of  the  disease. 

Impey,  who  has  had  a  large  personal  experience  with  leprosy  in 
South  Africa,  is  a  strong  believer  in  the  curability  of  leprosy.  He 
states  that  in  anaesthetic  leprosy  the  natural  course  of  events  is  for 
the  disease  to  expend  itself,  and  if  patients  could  only  stand  the  ter- 
rible battle  for  life  they  would  all  become  cured,  but  unfortunately 
the  strain  is  too  great  and  most  patients  die  before  the  bacilli  are  able 
to  work  out  their  own  destruction.  He  believes  that  the  interstitial 
inflammation  to  which  the  nerves  are  subjected  leads  to  a  contraction 
and  fibroid  degeneration  of  their  tissues,  so  that  the  sclerotic  condi- 
tion of  the  fibrous  baud  or  filament  which  represents  the  former  nerve 
trunk  presents  an  effectual  bar  to  any  further  growth  of  the  bacilli,  and 
these,  being  deprived  of  nourishment,  die.  Likewise  he  believes  that 
in  tubercular  lejjrosy  the  repeated  attacks  of  congestion  to  which  the 
tubercles  are  subjected  in  the  course  of  the  disease  produce,  in  like 
manner,  a  sort  of  fibroid  degeneration  of  tissues  and  this  sclerotic  tis- 
sue becomes  firmer  and  denser  in  consistence  and  thus  less  able  to 
support  a  mass  of  living  organisms.  He  believes  that  we  can,  in 
cases  not  too  far  advanced,  expedite  this  fibroid  degeneration  of  the 
tissues  and  thus  cure  tubercular  leprosy. 


574  MORROW — LEPROSY. 

The  commission  appointed  to  investigate  leprosy  in  the  Cai)e  of 
Good  Hope  reported  (1895)  that  they  believe  leprosj^  is  in  some  cases 
spontaneously  arrested  for  longer  or  shorter  periods,  and  in  a  small 
proportion  of  cases  the  arrest  is  permanent.  There  is  no  specific 
sign  by  which  permanent  arrest  can  be  recognized,  but  the  healing  of 
ulcers,  a  quiescent  state  of  the  skin,  a  general  appearance  of  good 
health,  increase  of  weight,  the  absence  of  au}^  indication  of  active  dis- 
ease, either  external  or  internal,  during  two  jears  may  be  regarded 
for  all  practicable  purposes  as  an  arrest  of  the  disease. 

I  believe  abortion  of  the  disease  occurs  in  the  early  stages  much 
ofteuer  than  is  generally  supposed;  leprosy  jjresentiug  in  this 
respect  a  striking  analogy  with  tuberculosis.  In  all  lej^rous  couu- 
tries  the  number  of  "suspects" — that  is,  persons  who  x^resent  sus- 
picious but  not  positive  unequivocal  signs  of  the  disease — is  very 
large.     Manj^  such  cases  are  classed  as  cases  of  lejirophobia. 

The  natural  process  of  cure  is  influenced  by  various  conditions. 
In  lepros3%  as  in  other  infectious  diseases,  morbid  processes  are  de- 
termined largely  by  conditions  of  aptitude  inherent  in  the  individual. 
Thus  the  question  of  soil  as  well  as  of  seed  has  to  be  considered.  If 
the  soil  is  unfavorable  as  a  culture  medium,  the  bacilli  die  of  inani- 
tion. The  only  explanation  of  this  spontaneous  cure  is  that  the  tis- 
sues of  these  individuals  are  endowed  with  an  unusual  capacity  of 
resistance  to  the  germination  and  growth  of  the  lepra  bacilli. 
This  capacity  of  resistance  may  be  strengthened  by  change  of  climate 
and  other  measures  to  be  considered  in  connection  with  hygiene  and 
treatment. 

TREATMENT. 

The  verdict  of  experience  is  that  leprosy,  in  the  vast  majority  of 
cases,  is  an  incurable  disease.  Of  the  large  number  of  remedies  and 
methods  of  treatment  employed  none  has  been  proved  to  possess  a  spe- 
cific curative  action  upon  the  leprous  process.  In  reviewing  the  litera- 
ture of  treatment  we  find  that  many  drugs  have  been  credited  with  exer- 
cising such  action,  but  when  this  clinical  testimony  is  analyzed  it  is 
found  to  be  of  the  most  conflicting  and  contradictory  character. 

In  estimating  the  value  of  treatment  certain  possible  sources  of 
error  should  be  considered.  The  study  of  the  natural  history  of  lej)- 
ros}',  abandoned  to  its  own  evolution  and  uninfluenced  by  treatment, 
shows  that  it  does  not  pursue  a  progressive,  uninterrupted  course : 
the  morbid  process  alternates  between  activity  and  repose ;  it  often 
presents  remissions  sufficiently  i)rolonged  and  complete  to  give  decep- 
tive indications  of  a  cure.  It  may  be  formulated  as  a  general  law 
that  recessions  are  the  rule  in  lepros}',  especially  in  the  earlier  stages. 


TEEATMENT.  575 

If  a  remedy  happens  to  be  given  wlien  such  a  remission  is  about  to 
occur,  the  observer  is  apt  to  attribute  the  spontaneous  subsidence  of 
symptoms  to  the  treatment  employed.  On  the  other  hand,  if  the  treat- 
ment is  instituted  coincidently  with  an  exacerbation  or  new  outbreak, 
it  is  condemned  as  a  failure.  In  the  writer's  opinion,  the  claims  of 
most  of  the  remedies  which  have  been  vaunted  as  "  specifics"  in  leprosy 
are  largely  based  upon  post  hoc  conclusions  as  to  results,  which,  right- 
fully interpreted,  are  mere  coincidences.  Again,  all  observation 
proves  that  under  the  sole  influence  of  climate  and  hygienic  treatment 
the  general  condition  of  leprous  patients  is  notably  improved. 

In  this  country  and  Europe  the  therapeutic  problem  is  compli- 
cated by  the  modifying  influence  of  climate  upon  the  course  of  the 
disease.  It  is  a  matter  of  observation  that  most  lepers  who  come  to 
this  country  get  better  for  a  time  at  least,  with  or  wiihout  medica- 
tion, and  when  treatment  is  employed  it  is  difiicult  to  differentiate 
between  its  effect  and  that  of  climate  and  improved  modes  of  living. 
Thus  in  a  case  of  pronounced  tubercular  leprosy  referred  to  me  some 
two  years  ago  by  a  colleague  in  New  York,  the  cutaneous  manifesta- 
tions entirely  disappeared  within  a  few  months  under  the  influence 
of  large  doses  of  Chaulmoogra  oil  internally,  with  daily  baths  and 
inunctions  of  Gurjun  oil.  In  another  patient  referred  to  me  several 
years  ago  by  Dr.  Besnier,  of  Paris,  there  has  been  an  apparent  cure 
from  the  use  of  phosphide  of  zinc  and  strychnine.  It  is  difiicult  to 
determine  what  precise  measure  of  curative  influence  should  be 
ascribed  to  the  drugs  in  these  cases,  since  in  another  case  under  obser- 
vation for  two  years  there  was  an  arrest  of  the  symptoms  under  the 
influence  of  hot  baths,  massage,  and  general  hygienic  measures — no 
drugs  whatever  having  been  administered. 

It  is  not  intended  to  jjass  in  review  the  innumerable  drugs  and 
methods  of  treatment  employed  in  the  treatment  of  leprosy.  It  would 
simply  serve  to  illustrate  the  fact  that  the  more  intractable  the  dis- 
ease the  more  numerous  the  remedies  advocated  for  its  treatment. 
The  early  methods  of  treatment  possess  an  antiquarian  rather  than  a 
practical  interest.  But  as  the  history  of  leprosy  is  embraced  within 
the  scope  of  this  article,  it  will  be  necessary,  for  the  sake  of  complete- 
ness, to  make  some  reference  to  the  methods  of  treatment  employed 
in  ancient  times. 

In  Mosaic  times  the  treatment  was  altogether  of  a  prophylactic 
character.  In  the  Hebraic  conception  of  the  disease  leprosy  was 
regarded  as  a  punishment  for  sin  and  an  evidence  of  divine  displeas- 
ure, and  the  only  hope  of  cure  was  through  divine  intervention.  The 
Levitical  code  gives  no  indications  of  the  employment  of  any  treat- 
ment directed  to  a  cure  of  the  disease. 


576  MORROW — LEPROSY. 

At  the  time  of  Galen  the  treatment  consisted  in  keeping  the  skin 
soft  and  moist  with  oily  applications  and  suitable  exercise.  Swim- 
ming was  particularly  recommended  as  combining  exercise  with 
bathing. 

Aretseus,  whose  graphic  description  of  leprosy  is  quoted  below  in 
the  section  on  History,  lays  down  as  the  proper  plan  of  treatment  the 
practice  of  frequent  and  copious  venesection,  followed  by  the  use  of 
purgatives,  baths,  and  inunction  of  fat,  associated  with  a  plain  nutri- 
tiou3  diet.  The  i)urgative  most  preferred  was  colocynth.  Among 
the  medicines  he  had  experience  of  may  be  mentioned  gum  vernix, 
brassica,  sideritis  (ironwort)  trefoil  with  wine  and  honey,  shavings  of 
elephants'  teeth  in  wine.  The  flesh  of  vipers  formed  into  pastils 
was  also  to  be  used  to  season  the  food.  The  compound  medicine 
was  made  from  levigated  alcyonium,  natron,  sulphur  viuum,  costus, 
iris,  and  pepper,  "  these  all  to  be  mixed  together  in  each  case 
according  to  the  power,  but  in  proportionate  quantities,  and  this  com- 
pound to  be  sprinkled  upon  the  body  and  rubbed  in.  For  the  callous 
protuberances  of  the  face  we  are  to  rub  in  the  ashes  of  vine  branches 
mixed  with  the  fat  of  wild  beasts,  as  the  lion,  tiger,  panther,  bear, 
etc. ,  or,  if  these  are  not  at  hand,  of  the  fat  of  the  barnacle  goose ;  for 
like  to  the  unlike,  as  the  ape  to  the  man,  is  most  excellent.  If  the 
flesh  be  in  a  livid  state,  scarifications  are  to  be  previously  made  for 
the  evacuation  of  the  humors.  Continued  baths  are  ordered  for  the 
purpose  of  humectating  the  body.  There  is  further  recommended 
natural  hot  baths  of  a  sulphurous  nature  and  protracted  residence  in 
the  waters  and  a  sea  voyage.  White  hellebore  is  recommended  above 
all  other  things;  for  in  power  white  hellebore  resembles  fire,  and 
whatever  fire  accomplishes  by  burning  still  more  does  hellebore  efi'ect 
by  penetrating  internally — out  of  dyspnoea  inducing  freedom  of 
breathing,  out  of  paleness  good  color,  and  out  of  emaciation  plump- 
ness of  flesh." 

Etius  follows  the  general  plan  of  treatment  described  by  Aretaeus, 
adding  that  amongst  the  Indians  it  was  customary  to  exhibit  as  "  a 
medicine  the  urine  of  the  ass,  probably  on  account  of  its  diuretic 
effects,  and  prescribe  as  an  article  of  diet  the  flesh  of  the  crocodile." 
Serpents  and  reptiles  seem  to  have  acquired  their  reputation,  in  this 
disease  and  other  diseases  in  which  the  skin  is  affected,  from  their 
periodical  exuviation  of  the  cuticle  and  the  magistral  inference  that 
their  flesh,  partaken  by  man,  would  enable  him  to  throw  off,  by  a 
similar  process  of  exuviation,  the  sordid  covering  of  morbid  secretions 
and  the  scales  which  are  apt  to  form  in  these  diseases  (Wilson). 

Paulus  ^gineta  recommended  practically  the  same  treatment  to 
be  employed  three  or  four  times  a  year.     In  his  list  of  medicines  are 


TREATMENT.  577 

mentioned  squills,  cumin,  calamint,  hartshorn,  theriac  of  salmis, 
and  theriac  of  vipers.  As  a  part  of  the  hygienic  treatment  he  recom- 
mended various  forms  of  gj^mnastic  exercise,  particularly  leaping,  the 
body  to  be  then  anointed  with  the  fat  of  some  animal,  as  of  the  boar, 
wolf,  goat,  or  bird,  or  with  butter.  After  inunction  the  patient  should 
take  a  bath  and  be  rubbed  with  some  stimulating  juice  or  spirit,  such 
as  fenugreek,  or  gum  ammoniac  dissolved  in  vinegar.  After  the 
bath  he  is  to  be  anointed  with  a  solution  of  gum  ammoniac  and  alum 
in  white  wine,  or  with  some  gently  stimulating  and  aromatic  oil,  such 
as  that  of  myrtle. 

Rhazes,  the  Arabian  physician,  commences  his  treatment  with 
emetics  and  reserves  venesection  for  cases  of  severity  or  of  long 
standing.  He  combines  turbith  with  colocynth  as  a  purgative  and 
favors  excitation  of  the  skin  by  means  of  friction  and  hot  baths,  and 
further  by  the  help  of  a  liniment  composed  of  onions  and  fennel,  or 
of  a  lotion  of  strong  acetic  acid  in  which  madder  root  has  been  for  a 
time  digested.  If  the  powers  of  the  constitution  be  reduced  by  the 
treatment,  he  recommends  the  use  of  good  white  wine  (Wilson). 

Daniellsen  and  Boeck  give  a  summary  of  the  treatment  recom- 
mended by  Schilling,  towards  the  end  of  the  eighteenth  century.  The 
diet  during  the  first  three  months  must  be  plain.  At  the  commence- 
ment of  the  cure,  so  long  as  the  "  obstruction"  lasts,  milk  must  not 
be  taken;  later  it  may  be  allowed.  Mercurials  are  abstained  from 
because  they  always  produce  in  lepers  violent  accidents  and  very  often 
a  dangerous  diarrhoea.  When  signs  of  plethora  are  present,  the  pa- 
tient must  be  well  bled. 

Warm  baths  should  be  employed,  but  carefully  in  advanced  stages 
of  the  complaint,  as  being  apt  to  occasion  palpitations  of  the  heart, 
convulsions,  and  fainting  fits.  He  encourages  exercise  for  the  pro- 
duction of  perspiration.  As  diluents  he  recommends  barley  water, 
gruel,  and  resolutive  herbs,  such  as  agrimony,  ground  ivy,  fumitory, 
arbrotanun,  veronica,  etc.,  and  tisanes,  to  which  are  sometimes  added 
demulcents  and  purgatives,  such  as  mallory,  rhubarb,  aniseed,  pelli- 
tory,  senna  leaves.  For  six  weeks  the  patient  should  drink  eight 
pounds  of  these  liquids  daily,  and  as  the  state  of  the  patient  or  the 
disease  indicates  he  bleeds,  purges,  or  adds  tonic  extracts  to  the  pre- 
ceding decoctions.  After  the  above  preparatory  course  of  six  weeks, 
the  more  powerful  alteratives  and  sudorifics  are  ordered,  especially 
soapwort,  sarsaparilla,  sassafras,  china  root,  juniper,  serpentary, 
scolopendrium,  pareira  brava,  and  other  similar  herbs.  The  greater 
the  consumption  of  these  decoctions,  he  claims,  the  more  prompt 
and  complete  the  cure.  The  body,  however,  he  remarks,  is  apt  to 
become  weak  under  this  treatment,  and  for  this  reason  good  and  nour- 
VoL.  XVIII.— 37 


578  MORROW — LEPROSY. 

isliing  food  and  good  wines  should  be  partaken  of.  He  prohibits 
acids  and  spirits  during  the  treatment,  as  being  liable  to  cause  febrile 
action.  After  having  employed  these  remedies  for  about  three  months 
it  is  advantageous  to  practise  bleeding  and  to  take  as  much  blood  as 
the  strength  of  the  patient  will  allow.  If  the  j^atient  makes  use  of 
these  curative  means,  he  should  avoid  cold  air,  as  it  maj-  happen  that 
a  critical  perspiration  is  suppressed  by  the  cold,  causing  severe 
diarrhoea. 

The  treatment  should  be  pursued  for  some  time  after  patients 
have  recovered  and  be  discontinued  by  degrees. 

It  will  be  perceived  that  many  of  the  methods  of  treatment  em- 
ployed in  ancient  times,  and  even  now  in  certain  countries,  seem  more 
like  incantations  than  rational  procedures.  In  Amoy  in  China,  for 
example,  "  the  leper  is  enclosed  in  the  carcass  of  a  freshly  eviscerated 
bullock,  where  he  remains  an  hour  or  more."'  A  snake,  the  flesh  of 
a  dead  child,  a  cooked  placenta  (human)  are  among  the  edibles  lauded 
by  the  Chinese  for  the  cure  of  leprosy.  In  Fatshan,  near  Canton, 
according  to  Dr.  McDonald,  "  lepers  have  a  notion  that  eating  the 
flesh  of  a  dead  child  will  cure  them." 

There  is  a  belief  prevalent  in  Canton  and  elsewhere  that  a  leprous 
woman  can  rid  herself  of  the  disease  by  having  connection  with 
a  healthy  man.  The  woman  by  connection  hopes  to  get  rid  of  the 
disease  by  handing  it  over  to  the  man.  This  curious  practice  is 
termed  "  selling  off  leprosy."  Another  curious  belief  prevailing  in 
China  is  that  sexual  intercourse  will  act  as  a  prophylactic  against 
leprosj".  Thus  a  woman  having  a  leproiis  husband,  but  who  herself 
shows  no  manifestations,  will  trj-  to  have  a  healthy  man  have  con- 
nection with  her,  thereby  lessening  her  chances  of  becoming  infected 
at  all. 

Dr.  Cantlie  reports  as  the  result  of  his  investigations  of  leprosy 
in  China  (1)  that  no  European  records  a  single  case  of  cure;  (2)  that 
no  native  drug  has  been  found  to  be  curative. 

Simpson  refers  to  a  certain  Christian  Livingstone  in  the  sixteenth 
century,  who  "  took  a  reid  cock,  slew  it,  baked  a  bannock  (cake) 
of  the  blood  of  it,  and  gave  the  same  to  a  leper  to  eat. "  Michael 
Scott's  cure  is  given  as  follows :  "  It  ought  to  be  known  that  the  blood 
of  dogs  and  of  infants  two  years  old  and  under,  when  diffused  through 
a  bath  of  heated  water,  dispels  leprosy  without  a  doubt"  (Thin). 

According  to  Erasmus  Wilson,  one  of  the  specific  remedies  ad- 
vocated in  the  treatment  of  elephantiasis  was  castration,  under  the 
impression  that  the  stimulus  given  to  the  blood  by  the  generative  sys- 
tem was  an  excitant  of  the  disease.  Patients  have  relieved  themselves 
of  these  glandular  organs,  but  without  any  benefit  whatever. 


TREATMENT.  579 

In  tlie  Middle  Ages  plilebotomr  was  recommended  to  expel  the 
excess  of  melancholy,  one  of  tlie  foiu-  liumors  wliicli  instead  of  going 
to  tlie  spleen  was,  in  leprosy,  diffused  tlirongliout  the  entire  body. 
In  conjunction  with  bleeding  the  use  of  laxative  medicines  and  fumi- 
gations, with  nasal  instillations  to  combat  the  nasal  deformities,  were 
employed.  This  treatment  was,  however,  considered  only  adjuvant 
to  the  specific  treatment  which  consisted  in  the  administration  of  the 
ilesh  of  vipers.  These  serpents  were  especially  prepared  and  the 
flesh  served  up  in  various  appetizing  ways — in  bouillon,  with  chicken, 
etc. ;  "  in  a  word,  it  was  to  be  absorbed  in  every  possible  way^in 
electuary,  in  distillation,  in  maceration."  This  mediaeval  practice 
has  been  mentioned  only  to  show  that  the  belief  upon  which  it  was 
based,  viz.,  that  there  exists  in  the  serpent  tribe  an  "antivenom" 
which  is  antagonistic  to  the  virus  of  leprosy,  has  prevailed  in  all  ages, 
and  it  still  survives  at  the  present  day.  According  to  Ashmead,  the 
antivenom  treatment,  which  consists  "  in  dissolving  the  snake  mamuslie 
in  wine  and  using  the  dissolution  internally,"  has  been  known  in 
Japan  for  a  thousand  years.  In  China  from  time  immemorial  the 
flesh  of  the  hungshe,  a  very  rare  snake,  dissolved  in  strong  wine  and 
taken  internally  has  been  regarded  as  a  cure  for  leprosy. 

In  South  America,  especially  among  the  Brazilians,  there  is  a 
widespread  faith  in  the  saving  efficacy  of  the  bite  of  serpents  against 
leprosy.  Dr.  Carreau,  in  1892,  reported  the  case  of  a  leper  bitten  by 
a  viper,  in  whom  there  was  a  remarkable  disappearance  of  the  tuber- 
cular lesions,  which  he  attributed  to  the  increase  of  hsemoglobin  in 
the  blood. 

According  to  Dr.  Laverde,  lepers  in  Colombia  cause  themselves  to 
be  bitten  by  venomous  serpents,  scorpions,  hornets,  etc.,  but  we 
possess  only  vague  information  as  to  the  results  of  this  barbaric 
therapeutics.  It  is  certain  that  the  result  is  often  fatal,  but  when  the 
patient  suiwives  there  is  a  remarkable  amelioration  in  the  symptoms, 
and  in  some  cases  a  permanent  cure  has  been  reported.  The  serpent 
corral,  whose  bite  is  rarely  fatal,  is  most  frequently  selected  for  this 
hazardous  procedure.  This  belief  in  the  immunizing  effect  of  snake 
poison  forms  the  basis  of  the  treatment  of  lej^rosy  by  the  antivenom 
serum  of  Calmette  and  Fraser,  which  will  be  again  refeiTed  to. 

The  treatment  instituted  by  Daniellsen  at  the  Lungegaards  Hospi- 
tal, Bergen,  was  based  on  the  theory  that  in  leprosy  there  is  an  excess 
of  albumin  and  fibrin  in  the  blood  and  that  the  abnormal  constitution 
of  this  fluid  could  be  best  corrected  by  vegetable  diet,  sulphur  baths, 
phosphoric  acid,  tarti^ate  of  antimony,  iodide  of  potassium,  iodide  of 
iron,  chlorine,  and  remedies  of  this  class.  Arsenic  was  used  spar- 
ingly and  in  small  doses.     Mercury  was  regarded  as  not  only  useless 


580  MORROW— LEPROSY. 

but  injurious.  In  some  cases  venesection  was  employed.  In  the 
local  treatment  of  the  tubercles  acid  nitrate  of  mercury  or  solution  of 
caustic  potash  was  used  for  their  destruction,  or  recourse  was  had  to 
caustic  or  sulphuretted  baths.  Daniellsen  also  employed  syphiliza- 
tion  on  the  theorj'  that  the  syphilitic  poison  might  prove  superior  to 
that  of  leprosy  and  the  production  of  a  sjq^hilitic  dj'scrasia  might  trans- 
form or  annihilate  that  of  leprosj' ;  the  result  was  that  the  syphilitic 
process  went  on  while  the  leprosy  remained  unchanged.  Iodide  of 
potassium  was  extensively  experimented  with  by  Daniellsen  with  good 
results  in  the  tubercular  form.  Leprous  patients  were  soon  found  to 
be  peculiarly  susceptible  to  its  irritant  effects  upon  the  skin,  and,  ac- 
cording to  Daniellsen,  it  affects  them  both  as  a  powerful  poison  and  a 
means  of  cure.  He  found  the  salicylate  of  sodium  effective  and  use- 
ful in  both  forms  of  lepros}'.  In  the  tubercular  form  the  newly  formed 
nodules  disappear,  but  old  nodules  of  long  standing  were  not  appar- 
ently affected.  The  external  application  of  a  concentrated  solution 
caused  the  nodules  to  disappear  partialh',  Viut  when  the  application 
was  discontinued  the  nodules  again  became  apparent.  Chaulmoogra 
oil  was  used  with  the  most  unsatisfactory  results,  as  it  seemed  to 
bring  out  severe  eruptions  of  nodules.  The  use  of  salicylate  of  mer- 
cury, though  this  was  borne  better  than  other  mercurial  prepara- 
tions, was  followed  by  no  improvement. 

Daniellsen  summarizes  the  results  of  his  long  and  extensive  ex- 
perience as  follows:  "I  have  employed  in  mj^  services  all  the  med- 
icaments which  have  been  so  much  vaunted  in  the  treatment  of  lep- 
rosy—all, from  the  iodide  of  potassium  to  that  of  chaulmoogra, 
gurjun  oil,  creosote,  etc.  They  have  been  sent  to  me  from  all  coua- 
tries.  I  have  oftentimes  had  moments  of  hope,  but  I  have  been 
forced  to  the  conviction,  which  I  must  again  repeat,  I  do  not  know  of 
a  medicament  which  cures  leprosy." 

Oil  of  Casheiv  Hiit  (Anacardium  occidenfale) . — A  plan  of  treat- 
ment which  attracted  considerable  attention  some  thirty  years  ago  was 
that  known  b}^  the  name  of  its  author  as  the  Beauperthuy  treatment. 
In  addition  to  a  careful  diet,  daily  baths,  etc. ,  he  sought  to  correct 
the  dyscrasia  by  the  administration  of  the  bichloride  of  mercury  in 
small  doses.  The  external  applications  were  liniments  to  cure  the 
eczematous  and  other  eruptions,  and  for  the  active  removal  of  the 
tubercles  a  strong  solution  of  nitrate  of  silver  and  copper  formed 
by  dissolving  silver  coin  in  .concentrated  nitric  acid  and  diluting 
with  an  equal  bulk  of  distilled  water;  but  principally  the  oil  of 
cashew  nut  (anacardium  occidentale)  was  employed  for  this  purpose. 
The  oil  of  cashew  was  applied  with  a  sponge,  or  a  needle  dipped  into 
it  would  be  used  to  puncture  a  tubercle  in  order  to  set  up  suppuration. 


TREATMENT.  581 

This  treatment  did  not  fulfil  tlie  high  expectations  which  had 
been  formed  of  its  curative  value.  It  was  tried  in  India,  Norway, 
and  elsewhere  and  abandoned.  The  cashew  nut  is  still  extensively 
employed  in  the  local  treatment  of  leprous, nodules. 

Hydrocotijle  asiatica  was  introduced  by  Dr.  Brileau,  of  Mauritius, 
himself  a  leper,  who  claimed  to  have  cured  himself  and  many  others 
with  this  drug.  According  to  Dr.  Lepine,  the  properties  of  the  plant 
are  due  to  an  active  principle  which  he  terms  vellarine.  It  appears 
to  have  a  i^eculiar  action  on  the  capillaries  of  the  mucous  surfaces  and 
upon  the  skin;  it  causes  first  a  sensation  of  heat  in  the  stomach  and 
at  the  same  time  a  prickling  in  the  extremities  and  then  over  the  skin 
of  the  whole  body,  followed  by  increased  transpiration,  etc.  From 
its  stimulatiag  effect  on  the  circulation  it  is  considered  to  be  espe- 
cially indicated  in  the  anaesthetic  form  of  the  disease. 

The  three  vegetable  remedies  which  have  been  most  highly  vaunted 
as  specifics  and  which  have  been  generally  held  in  highest  repute  are 
chaulmoogra  oil  and  gurjun  oil  and  Hoang-nan. 

CJiaulmoogra  oil,  expressed  from  the  seeds  of  the  Gynocardia  odo- 
rata,  which  probably  enjoys  the  highest  degree  of  professional  confi- 
dence, was  first  used  by  Le  Page,  of  Calcutta,  in  the  treatment  of  lep- 
rosy. It  is  given  in  doses  varying  from  five  to  eighty  drops  three  times 
a  day,  in  emulsion  or  in  capsules.  The  best  results  are  obtained  when 
large  doses,  two  hundred  to  three  hundred  minims  dailj'^,  are  admin- 
istered. Unfortunately,  the  oil  is  very  irritant  to  many  stomachs; 
some  cannot  tolerate  it  even  in  the  smallest  doses.  I  have  a  patient 
in  whom  a  dose  of  two  or  three  minims  invariably  causes  anorexia, 
disagreeable  eructations,  and  sometimes  vomiting.  In  cases  in 
which  the  oil  is  not  well  supported,  Yidal  has  recommended  its  ac- 
tive principle,  gynocardic  acid,  in  the  form  of  gynocardate  of  mag- 
nesium or  sodium,  given  in  capsules,  containing  20  to  30  cgm.  each. 
Of  these,  ten  to  twenty  may  be  taken  each  day.  Externally  chaul- 
moogra oil  may  be  used  in  the  proportion  of  one  part  of  the  oil  to  five 
or  fifteen  parts  of  olive  or  cocoanut  oil,  or  in  the  form  of  an  oint- 
ment of  gynocardic  acid.  Under  the  prolonged  use  of  chaulmoogra 
oil  it  is  claimed  that  there  is  a  notable  amelioration  of  the  symptoms 
■ — the  skin  becomes  soft  and  supple,  discolorations  clear  up,  leprous 
nodules  undergo  involution,  ulcers  heal,  disorders  of  sensibility  are 
corrected,  the  general  nutrition  improves,  and  the  patients  gain 
in  weight.  Numerous  physicians  have  published  cases  in  which 
decided  benefit  was  derived  from  the  use  of  this  drug.  It  seems 
to  have  the  best  effect  in  tubercular  cases.  Beaven  Rake,  Carter, 
and  many  physicians  who  have  largely  experimented  with  the 
drug,  testify  that  under  its  use  the  nodules  in  the  skin  subside  and 


582  MORROW — LEPROSY. 

the  sensory  nerves  more  or  less  regain  their  function.  Other  ob- 
servers, after  an  extensive  atrial,  have  not  been  impressed  with  the 
vahie  of  this  remedy. 

Gurjioi  oil,  derived  from  the  Dipterocarpus  turhinatiis,  first  recom- 
mended by  Dr.  Doiigall,  has  a  high  repute  in  India.  It  may  be  given 
in  an  emulsion,  e<]ual  parts  of  the  oil  and  lime  water,  the  dose  of  which 
is  frcnn  oue  to  four  drachms.  As  a  local  application  it  may  be  used 
in  the  proportion  of  oue  part  of  the  oil  to  three  parts  of  lime  water  or 
olive  oil.  To  secure  the  best  results  the  oil  should  be  rubbed  in  thor- 
oughl3%  two  hours  each  da}'  being  emploj'ed  in  the  process,  after  which 
a  bath  should  be  taken,  and  the  inunction  repeated  every  day.  Dr. 
Hillis  states  that  the  gurjun  oil  seems  to  exert  a  specific  action  on  the 
sweat  glands,  evidenced  by  the  increased  perspiration  and  return  of 
sensation  in  ansTesthetic  areas,  and  that  it  is  a  most  valuable  agent  in 
all  forms  of  leprosy-.  He  further  claims  that  hy  the  use  of  the  gurjun 
oil  in  suitable  cases  the  disease  may  be  arrested,  and  that  in  a  few 
instances  there  has  been  no  return  of  the  disease  for  over  two  years ; 
but  it  may,  nevertheless,  be  i)remature  to  sa\'  that  a  cure  has  taken 
place.  In  a  later  report  he  says :  "  In  gurjun  oil  we  appear  to  have  a 
most  valuable  medicine  for  the  treatment  of  leprosy  in  all  its  forms^ 
one  capable  of  retarding  the  ravages  of  the  disease  and  in  some  cases 
of  apparent!}'  curing  it." 

In  India  a  number  of  medical  officers,  Dr.  Neve  and  others,  report 
that  patients  improved  under  the  action  of  gui*jun  oil,  and  that  ulcers 
and  cracks  of -the  integument  particularly  healed  under  its  application. 

On  the  other  hand,  many  other  observers  have  tried  it  and  found  it 
of  no  particular  value.  Bidenkap  states  that  he  has  tried  it  without 
result,  although  the  frictions  connected  with  its  use  seem  to  have  a 
favorable  influence  upon  the  affections  of  the  cutaneous  nerves. 
Beaven  Rake  considers  that  the  value  of  gurjun  oil  has  been  greatly 
overrated,  although  he  concedes  that  its  external  application  is  of 
use  in  removing  scabs  or  desquamation.  Vandyke  Carter  also  de- 
preciates its  value,  declaring  that  the  results  are  disappointing. 

Hoang-nan  (Strychnos  gaultheriana)  is  a  remedy  which  has  been 
highly  extolled  in  China  and  other  countries  where  leprosy  prevails. 
It  comes  in  the  form  of  a  reddish  powder  from  the  bark  of  a  tree 
found  in  the  forests  of  Annam.  This  is  made  up  in  the  form  of  pills 
with  gluten.  Duriug  its  administration  all  alcoholic  drinks  are  sup- 
pressed and  a  simjjle  diet,  preferably  a  milk  diet,  is  recommended. 
The  remedy  should  be  used  with  care,  as  it  is  claimed  its  injudicious 
use  may  be  followed  by  tetanoid  symptoms.  I  have  known  of  one  case 
in  the  leper  settlement  of  Molokai  of  advanced  nerve  leprosy  in  which 
the  anaesthetic  symptoms  cleared  up  under  the  use  oi  Hoang-nan, 


TREATMENT.  583 

aud  the  improvement  has  contiuued  for  several  j-ears.  The  jiatieut 
regards  himself  as  practically  cured.  In  other  cases  the  beneficial 
effects  of  the  remedy  have  been  i)ronounced  and  positive. 

Stryc/niine,  the  active  principle  of  nux  vomica,  is  probably  closely- 
allied  in  its  action  to  Hoang-nan  and  has  been  largely  employed, 
and  with  excellent  results,  in  the  treatment  of  the  anaesthetic  form 
of  leprosy  in  this  countrj'. 

Ivhtlnjol. — Some  ten  years  ago  Unna  claimed  to  have  cured  two 
cases  by  the  internal  administration  of  ammonium  sulphoichthyolate 
and  the  external  use  of  certain  reducing  agents,  as  chrysarobiu, 
resorcin,  pyrogallol,  salicylic  acid,  etc.  The  reducing  agents  he 
asserted  to  be  most  effective  when  used  in  a  weak  strength,  in  five- 
to  ten-per-cent.  ointments.  In  some  cases  strong  ointments  of  chrys- 
arobiu or  plaster  mulls  containing  forty  parts  each  of  creosote  and 
salicylic  acid  were  applied  to  the  leprous  nodules  with  a  view  of 
exciting  an  inflammation  of  the  skin  and  effecting  an  elimination  of 
the  bacilli.  The  claim  that  the  i)atients  were  cured  was  premature, 
as  both  died  of  the  disease,  one  of  them  within  twelve  months.  A 
more  extensive  clinical  experience  by  others,  instead  of  confirming  the 
value  of  this  method  of  treatment,  has  demonstrated  it  to  be  a  failure. 

Salol,  which  has  been  highly  recommended  by  certain  observers, 
has  been  found  utterly  useless  by  others.  The  value  of  salol  was 
highly  extolled  b\'  Lutz,  He  claimed  that  in  large  doses  the  leprous 
fever  is  arrested  aud  the  eruption  retrogresses  with  the  healing  of  the 
ulcers;  anaesthetic  patches  again  become  sensitive,  and  the  scaly, 
shining  apjjearance  of  the  skin  gives  way  to  a  moist,  healthier  look. 
On  the  other  hand.  Dr.  Cook,  superintendent  of  the  Government 
Leper  Hospital  of  Madras,  after  an  extensive  experience  with  this 
drug,  declares  that  "  salol,  in  ni}^  opinion,  is  of  no  therapeutic  value 
— in  fact,  I  consider  it  a  decided  failure." 

Salicylicate  of  sodium  and  salicylic  acid  were  extensively  employed 
by  Daniellsen  and  Kobner,  who  state  that  these  remedies  are  effec- 
tive in  both  forms  of  leprosy.  In  the  tubercular  form  the  fever  is 
lessened,  the  eruptive  period  shortened,  and  some  nodules  disap- 
l^ear.  The  sodium  salicylate  was  given  in  doses  of  from  3  ss.  to  3  iss. 
(2  to  6  gm.)  daily.  Bidenkaj)  has  seen  more  harm  than  good  result 
from  the  use  of  salicylate  preparations. 

Creosote  ai)d  Carbolic  Acid. — Langerhans  and  Perez  claim  to  have 
had  excellent  results  from  the  internal  administration  of  creosote. 
Bidenkap  and  others  found  in  their  experience  creosote  and  carbolic 
acid  powerless. 

Europhen. — Dr.  Goldschmidt,  of  Madeira,  claims  to  have  cured 
incipient  tubercular  leprosy   by  the    application    of    europnen    oil 


684  MORROW — LEPROSY. 

(iodine  in  a  nascent  state).  In  cue  case,  after  six  years  there  had 
been  no  return  of  the  disease.  Alvarez,  of  Honolulu,  tried  the  euro- 
phen  treatment  with  "negative  results."  Havelburg,  of  Rio  Ja- 
neiro, has  used  europhen,  formalin,  and  nosophen  internally  and 
locally  as  salves  or  injected  into  tumors,  as  he  declares,  without  any 
real  effect  (Ashmead). 

Crude  Petroleum. — Kalindero  has  been  most  favorably  impressed 
with  the  use  of  crude  petroleum  from  which  he  has  observed  a  marked 
amelioration  of  the  leprous  symptoms. 

Chlorate  of  Potassium. — From  the  well-known  action  of  this  drug 
in  causing  a  rapid  increase  of  haemoglobin  in  the  blood,  Dr.  Carreau, 
of  Guadeloupe,  used  it  in  large  doses,  gr.  cl.  to  clxxx.  He  reports 
remarkable  results  from  its  employment,  shown  in  the  disappearance 
of  the  nodules  as  well  as  in  the  thickening  of  the  integument  and  resto- 
ration of  sensibility.  Beaveu  Hake  experimented  with  chlorate  of 
potassium,  but  with  unsatisfactory  results.  As  the  bacilli  are  not 
found  in  the  blood  it  is  difficult  to  see  how  a  modification  in  the 
composition  of  the  blood  affects  the  life  of  these  organisms. 

Airol  (oxyiodogallate  of  bismuth). — On  account  of  the  well- 
known  microbicidal  action  of  this  agent,  Fornara  emploj'ed  it  in  the 
treatment  of  leprosy.  He  injected  it  in  emulsion  (one-tenth  airol  with 
one-third  glycerin  or  olive  oil  previously  boiled)  in  tubercles,  plaques, 
swellings,  and  anaesthetic  areas,  graduating  the  dose  from  one  drop  to 
a  Pravaz  syringeful,  according  to  the  extent  of  the  lesions.  If  the  eyes 
were  attacked,  it  was  instilled  several  times  a  day  into  the  conjunctival 
sac.  If  the  nose  and  throat  were  involved,  the  powdered  drug  was 
snuffed  up  like  tobacco,  the  object  being  to  saturate  the  tissues  with 
airol.  In  some  cases  chaulmoogra  oil  was  also  used  internally  and  an 
ointment  of  the  oil  externally.  Fornara  reports  seven  cases  in  which 
there  was  either  a  cure  or  a  marked  amelioration  of  all  the  symp- 
toms. 

Formalin  has  been  extensivelj^  employed  in  the  treatment  of  lep- 
rosy on  account  of  its  germicidal  properties.  It  has  been  used  exter- 
nally as  a  caustic  and  in  frictions  rubbed  up  with  lanolin,  and  has  also 
boen  injected  into  the  tubercles.  When  it  is  thus  employed  the  tumor 
hardens  as  if  tanned  and  is  eliminated.  It  is  not  regarded,  however, 
as  superior  to  other  caustics  for  the  destruction  of  the  pathological 
formations  of  leprosy. 

PyoManin  is  another  bactericide  which  has  been  experimented 
with  in  the  treatment  of  leprosy.  The  tumors  into  which  it  was 
injected  assumed  a  blue  color,  small  abscesses  were  formed,  and  the 
necrotic  masses  were  eliminated,  but  it  was  found  to  have  no  effect 
on  the  general  manifestations  or  course  of  the  disease. 


TREATMENT.  585 

Thyroid  extract  is  a  remedy  which  has  been  experimented  with  on 
the  supposition  that  from  its  effect  in  reducing  mvxoedematous  infil- 
trations it  might  be  useful  in  the  diffuse  and  oedematous  infiltrations 
of  leprosy.  It  has  been  tried  extensively  in  South  America  and  by 
Alvarez,  of  Honolulu,  who  claims  that  it  has  a  remarkable  efficacy  in 
dissipating  the  oedematous  swellings  of  leprosy.  Its  continued  use 
does  not,  however,  modify  the  genera;l  condition  of  the  patient. 

Tuhercidin.— The  treatment  of  leprosy  by  injections  of  tuber- 
culin, which  was  introduced  some  years  ago,  is  mentioned  only 
to  be  condemned.  It  was  extensively  experimented  with,  but  the 
results  have  been  invariably  disappointing.  The  intense  vascular 
disturbance  produced  by  the  injections  is  so  marked  as  not  onlj-  to 
render  more  prominent  existing  leprous  infiltrations,  but  to  cause 
new  manifestations  of  the  disease  in  parts  previously  exempt.  In  a 
case  reported  by  Abraham,  after  the  third  injection  two  large  swell- 
ings resembling  nodes  apj^eared,  one  in  front  of  each  tibia ;  several 
tuberc]es  made  their  appearance  on  the  face,  forearms,  and  elsewhere, 
and  some  of  the  older  tuberosities  became  more  swollen.  In  a  case 
of  mixed  leprosy  under  my  observation  there  was  a  marked  aggrava- 
tion of  all  the  eruptive  features  with  the  development  of  new  foci  of 
the  disease.  In  another  of  my  cases  (anaesthetic)  there  was  no  change 
in  the  condition  of  the  patient  beyond  the  febrile  reactionary  effects. 
The  concurrent  testimony  of  almost  all  observers  is  to  the  effect  that 
the  action  of  tuberculin  is  positively  pernicious  in  determining  the 
development  of  new  foci  of  the  disease. 

Injections  of  Bovinine,  Meat  Juice,  etc.— J.  A.  Voorthuis  reports 
experiments  with  Unna's  method  of  treatment  of  lepra  v»'hich  was 
employed  in  the  cases  of  four  Chinesei  coolies  in  Deli  (Sumatra) ;  this 
consisted  in  intravenous  injections  of  Valentine's  meat  juice  thinned 
with  an  equal  part  of  artificial  serum,  0.2  to  1  c.c.  every  two  days. 
In  all  cases  there  was  a  bettering  of  the  general  condition  with  red- 
dening and  swelling  of  the  nodules,  which  then  softened  and  were 
resorbed  or  were  emptied  by  incision.  This  method  of  treatment  is 
based  upon  the  ground  that  the  muscular  tissue  which  is  dissolved  in 
meat  juice  is  the  only  particular  substance  of  the  body  which  is 
immune  to  the  lepra  bacilli. 

Intramuscular  Injections  of  PercMoride  of  3Iercu7-y.— Although. 
mercury  has  been  commonly  credited  with  exercising  a  positively 
injurious  action  in  leprosy,  exception  being,  perhaps,  made  for 
cases  in  which  there  is  a  combination  with  syphilis,  Crocker  re- 
ports five  cases  in  which  a  striking  improvement  was  manifest  after 
intramuscular  injections  of  perchloride  of  mercury.  He  is  positive 
that  the  improvement  was  not  a  matter  of  chance,  but  was  the  direct 


586  MORROW — LEPROSY. 

effect  of  the  treatment.  The  dose  is  cue-fourth  of  a  grain,  which  is 
injected  twice  a  week.  Crocker  notes  as  a  curious  circumstance  that 
none  of  the  patients  suffered  from  salivation,  nor  does  the  drug  ap- 
pear to  have  had  a  depressing  effect  when  used  twice  a  week  for 
many  months.  One  phenomenon  of  special  interest  was  observed 
in  all  cases,  viz.,  the  aj^pearance  in  different  parts  of  the  limbs  of 
hard,  pea-sized  nodules,  sometimes  cutaneous,  sometimes  subcuta- 
neously  seated,  which  were  unlike  the  leprosy  nodules.  They  were 
tender  at  first,  later  they  became  jjainless ;  some  persisted  for  months, 
others  disappeared  in  a  few  weeks  or  days. 

Formamide  of  Mercury. — Hasland,  of  Copenhagen,  has  reported 
remarkable  results  in  a  case  of  tubercular  leprosy  from  injections  of 
formamide  of  mercury.  One  injection  of  1  cgm.  of  the  drug  was  given 
daily,  except  when  the  treatment  was  interrupted  temporarily  by  in- 
tercurrent diarrhoea,  until  fifty-two  injections  had  been  made.  The 
patient  received  six  times  daily  a  tablespoonful  of  a  solution  of  salicy- 
late of  sodium  (10  :  300).  He  also  received  later  oleum  gynocardii, 
beginning  with  five-drop  doses  three  times  daily  and  increasing. 
Externally  an  ointment  of  ichthyol-salicylated  vaseline  was  used. 
The  ulcerations  were  cured,  the  tubercles  diminished  in  number, 
and  the  mucous  membranes  of  the  nose  and  pharynx  became  entirely  , 
smooth.  Later  there  was  a  relapse.  The  same  patient  was  seen 
later  by  Ehlers,  when  tubercles,  spots,  ulcerations,  and  swelling  of 
the  ulnar  nerve  were  found. 

Ehlers,  of  Copenhagen,  has  tried  the  injections  of  soluble  salts  of 
mercury  in  many  cases.  The  treatment  is  followed  by  immediate 
good  results,  but  it  does  not  prevent  recurrences. 

Antivenene  Treatment. — Dr.  Dyer,  of  New  Orleans,  impressed  with 
some  respect  for  the  popular  superstition  among  the  natives  of  South 
America  and  the  West  Indies,  that  the  bite  of  a  venomous  snake 
would  cure  leprosy,  experimented  with  Calmette's  antivenene  in  five 
cases  of  leprosy.  The  injections  were  made  everj'  other  day  at  first, 
subsequently  every  day.  The  dose  varied  from  1  to  11  c.c.  The 
total  number  of  injections  in  each  case  varied  from  ten  to  forty -two. 
The  regions  selected  for  the  injections  were  the  gluteal  or  interscapu- 
lar; in  some  instances  the  injections  were  made  in  the  nodular  lesions 
themselves.  Wherever  this  was  done  the  lesions  injected  disap- 
peared. In  four  out  of  the  five  cases  treated  by  antivenene  there  was 
marked  improvement ;  in  one  there  was  a  practical  disappearance  of 
the  lesion  i^resent  and  of  other  evidences  of  the  disease.  "Cold 
sweats"  was  the  most  characteristic  feature  of  the  constitutional  re- 
action following  the  injections. 

Erysipelas  and  its   Toxins. — Eeference  has  already  been  made  to 


TEEATMENT.  '  587 

the  observation  tliat  an  intercurrent  attack  of  erysipelas  lias  a  mark- 
edly modifying  effect  upon  tlie  manifestations  of  leprosy.  So  long 
ago  as  18h2  Campana  inoculated  two  leper  patients  with  the  products 
of  erysipelas.  The  lepers  were  not  cured,  but  all  the  other  pa- 
tients in  the  ward  contracted  erysipelas.  In  1891  Havelburg,  of  Rio 
Janeiro,  tried  injections  of  cultures  of  the  streptococci  of  erysipelas. 
He  found  that  the  reaction,  both  local  and  general,  was  so  violent 
that  the  experiments  had  to  be  discontinued.  A  serum  obtained 
from  animals  immunized  against  erysipelas,  prepared  by  Emmerich 
and  SchoU  of  Berlin,  was  then  substituted  for  the  erysipelas  cultures 
and  tried  in  the  cases  of  five  lepers.  The  injections  were  made  two  or 
three  times  a  week  in  the  lepromata  and  circumjacent  tissues,  and  each 
patient  received  from  fourteen  to  eighteen  injections.  The  effects 
were  variable.  Sometimes  no  local  reaction  whatever  -was  produced; 
at  other  times  phlegmons  and  abscesses  formed  precisely  as  after 
injections  of  pyoktanin,  alcohol,  or  phenic  acid.  The  treatment  was 
discontinued  on  account  of  the  unsatisfactory  results. 

Quite  recently  H.  D.  Chapin,  of  New  York,  has  published  the  re- 
sults of  his  treatment  of  four  lepers  in  the  City  Almshouse  by  the 
injections  of  the  mixed  unfiltered  toxins  of  the  streptococcus  of  ery- 
sipelas and  the  bacillus  prodigiosus  made  from  cultures  grown  to- 
gether in  bouillon.  The  injections,  beginning  with  one  minim  and 
gradually  increasing  to  twenty-two  minims,  were  continued  almost 
daily  for  about  two  months.  The  injections  produced  the  character- 
istic reactions  and  temperature  changes,  but  had  no  effect  upon  the 
course  of  the  disease. 

Impey  thinks  that  the  good  effects  of  an  attack  of  erysipelas  are 
due  not  to  an  antagonism  of  germs,  but  to  the  intense  inflammation 
which  brings  about  sufficient  degeneration  of  the  tissues  to  bar  the 
further  growth  of  the  bacilli  if  it  does  not  actually  cause  their 
destruction. 

Alvarez,  of  Honolulu,  has  been  experimenting  with  injections  of 
cultures  of  the  bacillus  prodigiosus,  but  without  curative  result. 

Serum  Therapy. — Among  the  more  recent  methods  of  treatment 
which  were  presented  and  discussed  before  the  Berlin  Leprosy  Con- 
gress may  be  mentioned  the  serum  treatment  of  Carrasquilla  with 
its  numerous  modifications  by  other  experimenters.  This  method 
of  treatment  was  invested  with  an  especial  interest  as  the  latest 
and  perhaps  most  promising  therapeutic  novelty.  To  Dr.  Juan  de 
D.  Carrasquilla,  of  Bogota,  Colombia,  is  due  the  credit  of  introduc- 
ing the  serum  treatment  of  leprosy.  His  serum  is  prepared  as  fol- 
lows :  A  leper  in  the  active  stage  of  the  disease  is  bled,  preferably 
during  one  of  the  periodical  exacerbations ;  the  blood  is  allowed  to 


588  MORROW— LEPEOSY. 

coagulate,  and  the  clear  serum  is  drawn  off.  This  serum  is  pre- 
served with  camphor  and  injected  into  a  horse ;  three  injections  of 
30  c.c.  each  being  given  at  intervals  of  ten  days.  The  horse  is  bled 
ten  days  after  the  last  injection,  after  which  Carras(iuilla  repeats  the 
same  process,  obtaining  at  the  end  of  each  month  a  progressively 
more  active  serum.  He  begins  by  injecting  into  a  leper  1  to  3  c.c. 
of  the  camphorated  horse  serum,  gradually  increasing  the  dose  to 
5  c.c,  and  injecting  on  alternate  days. 

He  claims  that  in  the  subjects  of  his  experiments  improvement 
began  in  a  week  and  was  marked  at  the  end  of  a  month.  He  de- 
scribes in  detail  a  number  of  cures,  over  two  hundred  in  all,  and 
sums  up  the  benefit  of  his  treatment  as  follows:  (1)  Eeestablish- 
meut  of  sensation ;  (2)  decoloration  of  blotches ;  (3)  disappearance 
of  oedematous  tubercles;  (4)  healing  of  ulcerations;  (5)  shrinking 
of  the  distorted  face.  He  maintains  that  the  morbid  process  ceases 
after  the  first  injection. 

J.  Olaya  Laverde,  of  Socorro,  one  of  the  most  enthusiastic  advo- 
cates of  the  employment  of  serum  in  leprosy,  has  introduced  certain 
modifications  in  the  method  of  its  preparation.  He  injects  asses 
and  goats  with  tlie  morbid  products  of  leprosy,  and  claims  that  he 
thus  obtains  a  more  active  serum.  He  collects  15  gm.  of  blood, 
25  gm.  of  lejiromes  which  he  triturates  and  adds  20  gm.  of  steril- 
ized water,  40  c.c.  of  which  is  at  once  injected  under  the  skin  of  a 
goat  in  the  scapular  or  pectoral  region.  The  animal  usually  suffers 
some  febrile  reaction  lasting  several  hours.  At  the  end  of  six 
or  eight  days  the  animal  is  bled  and  the  serum  is  injected  into  the 
patient,  the  quantit}'  varying  from  5  to  20  c.c.  The  injection  pro- 
duces a  febrile  reaction  more  or  less  marked,  sometimes  headache 
and  wandering  pains  in  the  lumbar  or  epigastric  region,  followed 
by  an  abundant  transpiration. 

Laverde  has  treated  about  sixtj^  patients,  many  of  them  receiving 
from  thirty-five  to  forty  injections.  He  reports  that  the  therapeutic 
results  are  most  satisfactory,  the  infiltrations  are  resorbed,  the  thick- 
enings clear  up,  the  spots  and  pigmentations  gradually  fade  out, 
the  tubercles  are  either  absorbed  or  break  down  and  disappear  by 
suppuration.  The  anaesthesia,  pain,  mucular  paresis,  and  other 
neuritic  symptoms  are  effaced,  the  patients  regain  the  use  of  their 
limbs,  etc. 

On  the  other  hand,  Putnam,  of  Colombia,  has  tried  the  Carras- 
quilla  treatment  on  forty  lepers  without  success. 

The  Oarrasquilla  serum  was  distributed  to  leprologists  for  ex- 
periment in  various  countries,  almost  all  of  whom  reported  adversely 
at  the  meeting  of  the  Berlin  Leprosy  Congress. 


TBEATMENT.  589 

Hallopeau  treated  six  cases  in  the  Hopital  St.  Louis  witli  nega- 
tive results.  Besnier  regarded  it  as  generally  unsatisfactory,  as  it 
produced  no  sensible  modification  of  the  disease. 

Alvarez,  of  Honolulu,  employed  the  treatment  in  fourteen  cases, 
two  of  which  were  improved.  He  often  observed  new  eruptions  dur- 
ing the  progress  of  the  treatment,  contrary  to  the  statement  of  Car- 
rasquilla,  that  after  the  first  injection  no  new  manifestations  of  the 
disease  appear.  He  observed  in  two  cases  severe  attacks  of  as- 
phyxia after  the  injections. 

Barillon,  Dehio,  Brieger,  Arning,  Doutrelepont,  and  others  ob- 
served no  favorable  result  whatever  from  the  serum  of  Carrasquilla, 
but  many  times  febrile  reactions  more  or  less  intense. 

A.  Griinfeld  employed  an  antileprous  serum  prepared  at  the  lab- 
oratory of  E.  Merck,  of  Darmstadt,  after  the  method  described  by 
Carrasquilla.  This  serum  was  injected  into  two  lepers  for  six  months. 
Dr.  Griinfeld  reported  a  notable  amelioration  of  the  general  condition 
of  his  patients  after  the  use  of  the  serum.  He  recommended  as  a 
necessar}^  condition  of  success  that  the  treatment  should  be  continued 
for  a  long  time. 

Herman  procured  the  clear  serum  from  leprous  nodules  by 
clamping,  incising,  and  pressing  out  the  exudation.  This  leprosy 
exudate  was  injected  into  a  horse  every  week  until  he  received  ten 
injections.  The  horse  was  bled  and  the  serum  collected  in  the  usual 
way.  This  serum  was  used  in  five  or  six  cases.  One  patient  was 
thought  to  be  improved,  but  the  results  could  by  no  means  be  con- 
sidered as  brilliant. 

Atherstone  and  Sinclair  Black,  of  the  Robben  Island  Asylum, 
made  a  number  of  experiments  with  the  Carrasquilla  serum  and 
the  "  antileprotic  serum"  of  Herman  and  at  the  same  time  made 
control  experiments  by  injections  in  other  cases  of  horse  serum, 
asses'  serum,  and  the  serum  of  patients  with  arrested  leprosy.  The 
results  were  far  from  establishing  the  specific  curative  action  of  any  of 
these  serums  upon  the  leprous  process.  The  injections  were  followed 
by  febrile  reactions,  headache,  and  profuse  perspiration,  but  "  the 
leprotic  process  suffered  no  arrest  of  a  marked  character." 

Independent  of  the  constitutional  reactions  the  serum  injections 
are  often  attended  with  the  formation  of  painful  swellings  and 
abscesses  at  the  points  of  injection.  "  The  skin  after  numerous  in- 
jections becomes  tender,  and  the  abscesses  are  very  apt  to  cause 
great  distress  to  the  patient,  even  when  the  strictest  antiseptic  pre- 
cautions have  been  employed  to  prevent  such  a  result." 

The  weak  point  in  the  serum  therapy  of  leprosy,  and  which  a 
priori  would  disqualify  it  from  a  scientific  standpoint,  is  that  neither 


590  MORKOW — LEPROSY. 

the  Carrasquilla  serum  nor  any  of  tlie  antileprotic  serums  cau  be 
considered  in  any  sense  as  representing  a  leprous  serum. 

Tlie  bacilli  leprso  are  not  habitually  found  in  the  blood.  Their 
presence  in  the  blood  current  during  an  attack  of  leprotic  fever  is 
purely  hypothetical;  therefore  in  injecting  the  blood  of  a  leper  into 
an  animal  there  is  no  i^robability  that  lei:)rous  germs  are  conveyed. 
Even  when  a  portion  of  lepromatous  tissue  or  the  serous  exudate  from 
a  tubercle  containing  bacilli  is  introduced  there  is  no  assurance  that 
the  bacilli  can  be  cultivated  in  the  blood  current  of  the  animal,  as  all 
experiments  prove  that  animals  are  refractory. 

Even  assuming  that  a  culture  of  lej^ra  bacilli  may  be  made  outside 
the  human  body  and  an  animal  be  found  susceptible  to  this  culture 
inoculation,  it  is  questionable  whether  the  serum  obtained  from  this 
animal  would  cure  leprosy.  In  the  case  of  tuberculin,  all  the  ideal 
conditions  for  the  production  of  a  perfect  serum  have  been  fulfilled, 
yet  the  results  of  the  i)ractical  employment  of  this  substance  in 
the  treatment  of  tuberculosis  have  been  most  disappointing. 

It  is  difficult  to  reconcile  the  enthusiastic  testimony  of  Carrasquilla 
and  Laverde  in  favor  of  the  beneficial  effects  of  serum  therapy  with 
the  almost  universal  condemnation  it  has  received  at  the  hands  of 
other  experimenters. 

The  same  may  be  said  of  the  clinical  testimony  as  to  the  thera- 
peutic value  of  a  long  list  of  remedies  which  are  highly  praised  by 
some  observers,  and  by  others  equally  competent  are  condemned  as 
useless  or  harmful.  We  thus  perceive  that  among  men  who  have  had 
the  largest  opportunities  for  experiment  there  is  a  most  unfortunate 
lack  of  unanimity  as  to  the  value  of  any  of  these  various  remedies, 
exception  being  possibly  made  for  chaulmoogra  and  gurjun  oil  and 
agents  of  the  Strychnos  family. 

While  many  of  the  remedies  and  methods  of  treatment  of  leprosy 
are  purely  empirical  and  without  rational  basis,  it  will  be  perceived 
that  most  of  the  agents  of  recent  introduction  have  been  employed  on 
account  of  their  bactericidal  properties.  It  is  evident,  however,  from 
the  position  of  the  bacilli  in  the  deeper  tissues  that  no  germicidal 
agent  can  be  brought  into  direct  contact  with  the  pathogenic  organ- 
isms ;  and  even  if  this  were  possible,  there  is  no  agent  capable  of 
destroying  the  bacilli  without  destroying  the  tissues  containing  them. 
The  true  indication  of  rational  treatment  would  seem  to  be  to  sterilize 
the  tissues  so  as  to  render  them  unsuitable  for  the  growth  and  multi- 
plication of  the  bacilli. 

Many  of  the  agents  employed  (chaulmoogra,  gurjun  oil,  and  many 
other  remedies),  it  is  claimed,  so  modify  the  economy  as  to  render  the 
tissues  sterile  and  inapt  for  the  nutrition  of  the  bacilli. 


TREATMENT.  591 

From  my  own  observation  and  experience  I  am  inclined  to  the 
^oelief  that  clianlmoogra  oil  exercises  a  more  directly  curative  action 
upon  the  manifestations  of  tubercular  leprosy  than  any  of  the  numer- 
ous drugs  which  have  been  recommended,  although  I  by  no  means 
share  the  enthusiastic  faith  of  those  who  claim  that  it  exerts  the  same 
specific  action  in  leprosy  that  mercury  does  in  syphilis.  In  order  to 
secure  the  full  measure  of  its  therapeutic  efficacy  it  should  be  given 
in  large  doses,  even  as  high  as  from  one  to  four  drachms  per  day. 
The  oil  does  not  seem  to  be  toxic,  but  it  possesses  the  unfortunate 
disadvantage  of  being  extremely  nauseating,  so  that  many  patients 
cannot  take  it,  even  in  small  doses,  without  experiencing  disagreeable 
eructations  and  sometimes  nausea  and  vomiting.  The  administration 
of  the  oil  in  capsules,  followed  by  a  drink  of  tea  or  a  little  rum,  ren- 
ders the  stomach  more  tolerant  of  its  presence. 

In  other  cases  recourse  may  be  had  to  its  active  medicinal  prin- 
ciple, gynocardic  acid,  combined  with  sodium  or  magnesium.  I 
have  found  the  gynocardate  of  magnesium  much  better  tolerated  than 
the  pure  oil  and  apparently  equally  effective. 

Hot  baths  and  inunctions  of  gurjun  oil  with  massage  will  be  found 
useful  in  both  forms  of  leprosy.  Hoang-nan  is  a  remeds^  which  finds 
its  special  application  in  cases  of  the  anaesthetic  type.  As  this  is 
not  an  easily  procurable  drug  in  this  country,  I  have  treated  most 
anaesthetic  cases  with  preparations  of  strychnine,  which  may  be  used 
either  alone  or  advantageously  combined  with  phosphorus,  iron,  and 
other  nerve  and  ferruginous  tonics. 

Electricity  is  an  agent  which  has  proven  in  my  experience  espe- 
cially serviceable  in  restoring  impaired  or  lost  sensibility  in  anaesthetic 
areas.  The  condition  of  success  is,  however,  that  it  should  be  used 
faithfully  and  for  a  long  period. 

The  case  of  which  a  short  history  is  given  on  page  513  continued 
under  my  observation  several  years,  and  the  results  of  the  treatment 
were  so  satisfactory  as  to  justify  its  description. 

The  patient  was  first  given  chaulmoogra  oil  in  capsules,  but  on 
account  of  the  gastric  and  intestinal  irritation  occasioned  by  the 
drug  its  use  for  any  continued  length  of  time  was  impossible.  The 
gynocardate  of  magnesium  was  substituted,  but  even  this  occasioned 
some  gastric  irritation^  though  much  less  pronounced  than  when  the 
pure  oil  was  used.  For  some  time  the  patient  received  injections  of 
tuberculin;  there  was  some  constitutional  reaction  of  a  very  pro- 
nounced character,  but  the  influence  of  the  remedy  upon  the  disease 
seemed  to  be  absolutely  nil.  Finally  the  patient  was  placed  upon 
the  phosphide  of  zinc  and  strychnine,  the  use  of  which  was  continued 
with  intermissions  for  two  or  three  years. 


592  MOBROtr— LEPROSY. 

Electricity  was  first  employed  in  order  to  restore,  if  possible,  the 
seusation  in  the  ausesthetic  patch  over  the  instep.  The  result  waS 
exceedingh'  slow,  but  quite  satisfactory.  Th3  normal  sensation  re- 
turned in  the  course  of  trv-o  years.  The  electricity  was  also  applied 
along  the  course  of  the  sciatic  and  ulnar  nerves,  which  had  shown 
evidence  of  commencing  degeneration  manifest  in  a  tendency  of  the 
limbs  to  go  to  sleep,  with  more  or  less  numbness  and  loss  of  sensi- 
bility of  the  hands  and  feet. 

The  patient  continued  the  use  of  the  electricity  for  three  or  four 
years.  At  the  last  examination  two  years  ago  it  was  found  that  the 
hj'perchromatic  margin  of  the  patch  over  the  instep  was  broken  and 
disappearing  at  certain  points.  The  other  macular  lesions  were  also 
in  process  of  disappearance.  The  patient  wrote  recently  (October, 
1898)  that  she  thought  she  was  entirely  well  of  her  trouble. 

As  before  intimated,  patients  coming  to  this  country  may  show 
signs  of  improvement,  for  a  time  at  least,  with  or  without  treatment, 
and  it  is  sometimes  difficult  to  assign  the  true  measure  of  therapeutic 
efficacy'  to  the  drugs  employed.  It  is  to  be  observed,  however,  that 
although  leprosy  seems  to  pursue  a  milder  and  a,  longer  course  in  this 
country,  it  almost  invariably  progresses  to  a  fatal  termination,  and 
due  credit  should  he  given  to  any  treatment  which  arrests  its  further 
progress. 

One  explanation  of  the  conflicting  character  of  this  clinical  testi- 
monj'  is  found  in  the  nature  of  the  disease.  Leprosy  always  runs  a 
protracted  but  exceedingly  variable  course,  periods  of  active  invasion 
being  followed  by  periods  of  latency  and  even  improvement,  and  when 
retrogression  of  the  symptoms  occurs  it  is  difficult  to  estimate  the 
part  contributed  by  treatment  to  this  result. 

Again,  in  experimenting  with  a  new  remedy  the  physician  is  apt  to 
select  such  cases  as  are  not  far  advanced  and  in  fairly  good  condition. 
These  patients  are  commonly  placed  in  good  hygienic  conditions, 
supplied  with  better  food,  and  are  the  objects  of  daily  individual 
attention.  It  is  well  known  that  leprous  catients  often  have  pe- 
riods of  great  improvement  and  even  apparent  ari'est  of  the  disease 
under  the  influence  of  hygienic  treatment  alone;  hence  there  may  be 
a  fallacious  deduction  in  ascribing  the  improvement  to  the  specific 
action  of  the  remedy  employed. 

Another  reason  of  this  contradictory  testimony  as  to  the  value  of 
a  special  mode  of  treatment  is  that  one  observer  may  find  it  beneficial 
after  prolonged  use,  while  another  condemns  it  npon  an  insufficient 
test.  The  more  we  study  leprocy  the  more  we  are  convinced  of  the 
fact  that  the  essential  condition  of  successful  treatment  is  that  it 
should  be  perseveringly  continued  for  months  and  years.     At  one 


TEEATMENT.  593 

time  a  six  weeks'  and  later  a  six  months'  treatment  of  syphilis  was 
regarded  as  quite  sufficient,  but  at  the  present  we  recognize  that  the 
treatment  should  be  prolonged  for  a  period  of  years  corresponding  to 
the  natural  life  term  of  the  malady.  Doubtless  one  reason  of  the 
almost  uniform  failure  of  all  treatment  instituted  for  leprosy  is  that 
it  is  not  sufficiently  prolonged,  the  recession  of  symptoms  being 
taken  both  by  the  physician  and  patient  as  an  indication  of  cure  and 
a  signal  for  the  cessation  of  treatment. 

In  most  leprous  countries  it  is  difficult  to  subject  the  patient  to  a 
course  of  treatment  sufficiently  prolonged  and  energetically  carried 
out  to  judge  of  its  value.  In  leper  hospitals  and  communities  most 
patients  are  impressed  with  the  futility  of  all  hopes  of  cure  and  soon 
tire  of  systematic  treatment.  In  the  leper  settlement  of  Molokai  the 
resident  physician  has  given  it  as  the  result  of  his  experience  that 
"  the  scientific  treatment  of  leprosy  cannot  be  carried  out  because  not 
more  than  ten  per  cent,  of  the  patients  will  continue  it  for  six 
months." 

The  "Japanese  treatment,"  which  consists  of  a  system  of  baths 
and  tonics,  has  been  more  thoroughly  tried  in  the  Molokai  settlement 
than  any  other  method.  Dr.  Gotto  was  employed  by  the  Hawaiian 
Government,  and  special  baths  were  especially  fitted  up  to  enable 
him  to  apply  his  method.  The  treatment  has  fallen  into  disfavor  and 
been  practically  abandoned.  In  a  letter  from  Mr.  Dutton  the  effects 
of  this  treatment  are  incidentally  referred  to  as  follows :  "  The  Japa- 
nese so-called  '  remedies  '  act  as  a  check.  For  some  years  the  check- 
ing process  continues  if  the  rules  as  to  medication,  baths,  etc.,  are 
closely  followed.  The  pains  are  lessened  at  times,  but  the  bodj^  seems 
to  become  weaker,  and  I  doubt  if  the  final  result  is  of  great  benefit. 
"We  still  use  the  hot  baths,  but  not  so  frequently  as  the  Japanese  sys- 
tem requires — three  times  a  week  instead  of  three  times  a  day.  The 
effects  are  good  in  inducing  cleanliness  and  also  in  causing  perspira- 
tion, if  care  is  taken  not  to  catch  cold." 

In  addition  to  the  numerous  remedies  which  have  been  employed 
on  the  assumption  that  they  exerted  a  more  or  less  special  action 
upon  the  leprous  process  there  are  many  drugs  which  have  been 
used  in  the  symptomatic  treatment  of  the  disease,  and  often  with  good 
effect,  such  as  quinine,  arsenic,  opium,  antipyrin,  and  bromide  of 
potassium.  The  latter  drug,  according  to  Besnier,  is  exceedingly 
useful  as  a  nervine.  Tonics,  iron,  cod-liver  oil,  and  reconstituent 
remedies  generally  are  found  most  serviceable  in  improving  the  tone 
of  the  system  and  counteracting  the  angemic  condition  so  commonly 
present  in  this  disease. 

The  visceral  complications  of  leprosy  which  ordinarily  supervene 
Vol.  XVin.-38 


594  MORROW — LEPROSY. 

at  a  more  advanced  stage,  sucli  as  broncliial,  renal,  and  gastrointesti- 
nal disorders,  should  be  treated  symptomaticall3^  Paracentesis  is 
occasionally  necessary  for  the  dropsy  which  accompanies  the  renal 
disease  so  common  in  leprosy.  Beaven  Rake  found  the  kidneys 
diseased  in  twenty -five  per  cent,  of  the  autopsies  on  lepers. 

Local  Treatment. 

In  the  systematic  treatment  of  leprosy  local  applications  have 
proven  a  most  valuable  adjunct.  Chaulmoogra  and  gurjun  oils  are 
not  only  applied  locally  in  conjunction  with  the  internal  administra- 
tion of  these  drugs,  but  in  many  cases  in  which  the  latter  occasions 
much  gastric  irritation  their  use  by  inunction  alone  has  been  found  to 
exercise  quite  a  beneficial  influence  in  causing  to  disappear  the  nodu- 
lar lesions  as  well  as  the  diffused  infiltrations  of  the  integument.  The 
admixture  of  these  oils  with  vaseline  or  lanolin  in  variable  propor- 
tions has  been  recommended  when  they  are  to  be  applied  over  a  large 
surface. 

The  use  of  baths  followed  by  inunctions  with  oils  or  fats  seems  to 
have  been  practised  in  all  ages.  The  ancients  attributed  especial 
virtues  to  the  fats  of  certain  animals,  as  the  lion,  the  bear,  the  boar, 
and  the  panther. 

One  condition  of  the  good  effects  of  oily  preparations  is  that  they 
should  be  thoroughly  rubbed  in  and  their  use  continued  for  a  long 
period.  It  has  been  said  that  to  be  cured  of  leprosy  one  must  live  in 
grease  for  months  and  years.  The  external  use  of  linseed  oil,  cacao 
butter,  or  cod-liver  oil  would  probably  be  followed  by  equally  good 
results  as  have  been  claimed  from  the  use  of  chaulmoogra  or  gurjun 
oil;  the  chief  benefit,  in  my  opinion,  being  derived  from  the  two 
hours'  daily  rubbing  required  in  their  inunction. 

The  local  treatment  of  the  tubercles  and  ulcers,  necrosed  bones, 
and  other  individual  lesions  of  leprosy  should  be  conducted  on  gen- 
eral surgical  principles.  In  allaying  inflammation,  removing  necrosed 
tissues,  and  promoting  the  healing  process  the  resources  of  modern 
aseptic  surgery  may  be  most  advantageously  employed.  The  ex- 
istence of  leprosy  can  scarcely  be  considered  a  contraindication  to 
any  required  operation,  a^  the  tissues  heal  with  remarkable  facility 
owing,  as  has  been  suggested,  to  the  excess  of  fibrin  in  the  blood. 
By  Daniellsen  and  Boeck  the  proj^ortion  of  fibrin  in  the  blood  of 
lepers  has  been  estimated  from  0.22  to  0.6  per  cent.  Beaven  Bake 
found  in  fifty  carefully  conducted  analyses  that  the  percentage  ranged 
from  0.12  to  1.87,  the  average  being  0.76,  which  is  a  marked  excess 
over  the  normal  proportion,  0.2  per  cent.     He  attributed  the  rapid 


LOCAL  TEEATMENT.  595 

healing  of  incisions  in  lepers  to  the  very  rapid  clotting  which  takes 
place  in  their  blood.  Tubercles  may  be  excised,  ulcers  may  be 
scraped,  deep  incisions  made,  necrosed  bones  removed,  and  amputa- 
tions performed  with  the  certainty  of  more  or  less  prompt  cicatriza- 
tion. 

Dressings. — A  variety  of  dressings,  both  wet  and  dry,  have  been 
emploj'ed  for  the  healing  of  the  ulcerations  and  for  their  aseptic 
properties.  Lotions  of  the  sulphate  of  copper  (gr.  iv.  to  3  i.),  of 
carbolic  acid  (1 :  40),  of  corrosive  sublimate  (1 : 2,000  or  1 :  3,000)  have 
been  employed.  A  lotion  of  the  permanganate  of  potassium  is  prob- 
ably the  most  extensively  used.  Many  of  the  powders  which  are  used 
in  the  treatment  of  ordinary  ulcerations  have  been  employed  for  their 
aseptic  and  presumed  germicidal  properties,  such  as  iodoform,  iodol, 
aristol,  europhen,  saliphen,  nosophen,  airol,  etc.  Creolin  was  re- 
garded by  Beaven  Eake  as  a  most  excellent  stimulant  for  indolent 
leprous  ulcers.  Pure  creolin  was  used  by  him  as  a  caustic  to  prevent 
recurrence  of  leprous  tubercles  after  excision. 

Ointments  are  most  in  favor  with  leprous  patients,  as  they  do  not 
dry,  necessitating  frequent  application,  and  do  not  form  crusts. 
Iodoform  ointment  is  declared  by  many  to  be  the  most  useful  of 
external  applications.  It  not  only  acts  beneficially  upon  the  open 
surfaces,  but  it  masks  by  its  penetrating  odor  the  still  more  disagree- 
able foetor  which  arises  from  the  leprous  discharges. 

Reference  has  already  been  made  to  the  local  use  of  ichthyol, 
chrysarobin,  resorcin,  pyrogallol,  and  other  reducing  agents  in  the 
systematic  treatment  of  leprosy.  I  have  used  these  agents  in  a  num- 
ber of  cases  without  being  able  to  satisfy  myself  that  they  were  pro- 
ductive of  any  benefit.  In  estimating  the  value  of  such  measures,  it 
is  well  to  bear  in  mind  the  spontaneous  tendencj^  of  the  patches  to 
fade  with  a  return  of  normal  sensation  and  function.  In  one  case  I 
noticed  the  disappearance  of  patches  under  the  application  of  caustic 
pyrozone,  and  in  another  under  a  strong  application  of  menthol  which 
was  continuously  employed  for  a  lengthened  period. 

Surgical  measures  play  a  much  more  important  role  in  the  treat- 
ment of  anaesthetic  leprosy  than  of  the  tubercular  form.  Of  1,996 
operations  performed  within  six  years  at  the  Trinidad  Asylum, 
Beaven  Eake  states  that  1,489  were  done  on  anaesthetic  males  and  88 
on  anaesthetic  females.  Among  tubercular  cases  there  were  83  opera- 
tions on  males  and  26  on  females.  In  cases  of  mixed  leprosy  the 
operations  on  males  numbered  300  and  those  on  females  10.  The 
greater  preponderance  of  operations  on  males  is  explained  by  the 
fact  that  they  are  more  exposed  from  their  outdoor  work  tO  injuries 
which  result  in  ulcers  and  necroses. 


596  MORROW — LEPROSY. 

Removal  of  Tubercles  by  Excision  or  Destructive  Cauterization.  — 
The  obliteration  of  tubercles  lias  long  been  recognized  as  a  correct 
surgical  procedure,  especially  in  the  early  stages  and  when  they  are 
localized  on  the  face  and  extremities.  Daniellsen  was  accustomed  to 
effect  this  by  destructive  cauterization  with  caustic  potash  or  the  acid 
nitrate  of  mercury ;  nitric,  carbolic,  salicylic,  pyrogallic  acids,  and 
various  caustics  have  been  employed  for  this  purpose.  Destruction 
of  the  tubercles  has  also  been  effected  by  the  injection  into  their  sub- 
stance of  various  irritant  and  escharotic  substances,  as  oleum  auacar- 
dii,  pyoktanin,  alcohol,  carbolic  acid,  etc.  The  inflammatory  reac- 
tion thus  induced  proceeds  to  suppuration,  the  breaking  down  of  the 
nodules,  and  the  discharge  of  their  contents,  after  which  cicatrization 
takes  place. 

A  very  satisfactory  method  of  destroying  the  nodules  is  by  the 
use  of  the  thermocautery,  either  with  or  without  preliminary  removal 
of  the  mass  with  the  curette.  This  procedure  is  preferred  by  many 
surgeons,  as  the  operation  is  easily  done,  and  it  gives  a  better  cos- 
metic result  in  the  shape  of  a  smooth  cicatrix.  In  using  potential 
caustics  the  depth  and  extent  of  the  destructive  action  cannot  be  so 
accurately  limited. 

I  have  a  number  of  times  excised  tubercles  or  destroyed  them  with 
caustic  potash,  and  the  wounds  healed  promptly.  The  same  proce- 
dure may  be  emploj^ed  in  removiug  circumscribed  masses  of  tubercles 
along  the  superciliary  ridge  or  elsewhere.  Unfortunately  the  tuber- 
cles may  reappear  in  the  skin  around  tlie  cicatrices,  but  for  a  time  at 
least  the  effect  upon  the  patient's  general  condition  is  most  salutary. 
In  one  case  I  excised  a  piece  of  pigmented  skin  from  the  back  of  an 
anaesthetic  patient.  Although  the  line  of  incision  was  carried  well 
be^^ond  the  pigmented  border,  the  pigmentation  became  a  year  later 
well  marked  in  the  skin  surrounding  the  cicatrix. 

The  occurrence  of  gangrene,  necrosis  of  bones,  perforating  ulcers 
involving  not  only  the  extremities,  but  threatening  important  organs, 
as  the  nose,  throat,  and  larynx,  has  necessitated  a  number  of  surgical 
expedients. 

An  I  fi  I  tat  ions  through  the  thigh,  knee,  leg,  ankle,  or  arm  are  most 
frequently  performed  for  leprous  gangrene  and  ulceration  of  the 
extremities. 

Perforating  Ulcer. — Free  incisions  down  to  the  bone  in  perforating 
ulcers  and  sinuses  leading  to  dead  bone  give  great  relief  from  pain. 
In  all  cases  the  incision  should  be  sufficient  to  permit  the  removal  of 
all  necrosed  bone  to  insure  healing. 

In  perforating  ulcers  of  the  sole,  Beaven  Rake  recommends  that 
the  bistoury  be  thrust  through  the  foot  from  the  sole,  coming  out 


LOCAL  TREATMENT.  597 

througli  the  dorsum  or  between  tlie  toes ;  if  the  ulcer  is  near  one  side, 
the  knife  should  be  brought  out  laterally,  the  gaping  wound  being 
packed  with  lint  and  allowed  to  granulate. 

In  deep  ulcerations  of  the  lower  extremity,  which  interfere  seri- 
ously with  the  patient's  comfort  and  locomotion,  the  gangrenous  flesh 
should  be  cut  away,  any  necrosed  bone  removed,  and  the  parts  dressed 
aseptically.  Amputation  maj  be  employed  in  gangrene  of  the  fingers 
and  toes,  as  it  gives  a  better  result  than  the  spontaneous  amputation 
of  nature. 

T\Tien  the  bone  comes  away  piecemeal,  as  it  often  does  in  these 
cases,  the  process  is  long  and  painful,  and  a  flail-like  condition  of  the 
member  is  apt  to  ensue. 

Of  the  830  removals  of  bone  in  Beaven  Kake's  series  of  cases,  532 
were  in  anaesthetic  lepers,  6  in  tubercular  lepers,  and  92  in  cases  of 
the  mixed  type. 

"In  diffuse  brawny  swellings  without  suppuration  of  the  lower 
extremities,  long  free  incisions  from  the  knee  to  the  ankle  or  from 
the  ankle  to  the  toes  are  recommended,  as  they  relieve  pain  and  ten- 
sion from  the  oedematous  infiltration. 

Operations  on  the  hands  and  feet  of  anaesthetic  patients  may  be 
performed  in  many  instances  without  anaesthetics  as  the  parts  are 
devoid  of  sensation.  Patients  frequently  chop  oft^  a  useless  member 
without  flinching. 

N erve-str etching ,  for  the  relief  of  distressing  neuralgia  and  pain 
along  the  course  of  nerves,  and  the  heahng  of  perforating  ulcers  in 
areas  supplied  by  the  nerves,  has  been  practised  by  Beaven  Bake, 
Neve,  and  others  with  good  results. 

Neve,  of  Kashmir,  reports  that  in  100  cases  of  leprosy  the  nei-ves 
were  stretched  270  times.  Great  improvement  was  noted  in  the  tracts 
supplied  by  the  nerves,  except  in  the  face  and  parts  supplied  by  the 
cranial  nerves.  Neve  regards  "nerve-stretching  most  valuable  as  a 
palliative." 

Beaven  Eake  practised  this  procedure  113  times  on  lepers  in  the 
Trinidad  Asylum.  He  gives  detailed  accounts  of  the  results  in  100 
operations  on  60  patients :  the  sciatic  was  stretched  26  times,  the  ex- 
ternal popliteal  11  times,  the  median  14  times,  the  ulnar  at  the  elbow 
18  times  and  above  the  wrist  4  times,  and  the  supraorbital  once. 

The  operation  was  done  for  ulceration  38  times ;  for  pain  9  times ; 
for  anaesthesia  33  times;  pain  vanished  at  once,  with  some  improve- 
ment, though  not  complete  or  permanent;  in  tubercular  cases  18 
times;  no  result.  About  one-half  of  the  patients  were  benefited. 
Eake  thought  that  the  chief  value  of  the  operation  was  demonsti-ated 
in  perforating  ulcer,  some  cases  of  necrosis  and  pain  associated  with 


598  MORROW— LEPROSY. 

perforating  ulcer  or  peripheral  neuritis.  He  found  that  the  nerves 
operated  on  were  enlarged  in  48  cases. 

Beaveu  Rake's  theory  of  the  rationale  of  this  operation  is  that  the 
results  are  due  to  changes  in  the  spinal  ganglia  produced  by  the 
stretching.  Another  theory  is  that  the  stretching  to  which  the  swollen 
and  congested  nerves  are  subjected  empties  the  blood-vessels  and 
lymphatic  spaces  of  the  affected  part,  and  thus  relieves  the  congestion 
and  improves  the  condition  of  the  patient. 

The  ocular  lesions  of  leprosy  are  very  common  and  most  dis- 
tressing. Leloir  noted  that  of  64  lepers  at  Molde,  in  Norway,  41 
had  ophthalmic  lesions,  37  in  both  eyes,  while  6  were  entirely 
blind.  When  there  was  an  invasion  of  the  cornea,  Daniellsen  and 
Boeck  arrested  the  progress  of  the  tubercles  by  cauterizing  the 
conjunctiva  or  cornea  around  the  tubercles.  The  tubercles  which 
form  on  the  conjunctiva  may  be  removed  from  time  to  time  with 
curved  scissors.  Kaurin  performed  keratotomy  for  the  same  pur- 
pose. Ligation  of  the  vessels  sup^jlying  the  tubercles  has  been  suc- 
cessfully done.  The  operation  sometimes  checks  the  growth  of  the 
tubercles  temporarily,  but  it  is  only  palliative.  As  soon  as  the  col- 
lateral circulation  becomes  established  the  tubercle  again  increases. 
Various  delicate  operations  have  been  successfully^  I)erformed  with 
the  object  of  correcting  the  epiphora  and  other  disagreeable  sj'mp- 
toms  which  result  from  the  paralj^sis  of  the  orbicular  muscle  and  con- 
sequent inability  to  close  the  eyelids.  For  paralytic  ectropion  Kau- 
rin performed  tarsorrhaphy  of  the  inner  third  of  the  eyelids,  thus 
raising  the  lower  lid  and  permitting  their  closure.  Cataract  is 
common  in  leprosj^  and  extraction  maj  be  successfulh'  performed, 
oftentimes  without  an  anaesthetic,  as  the  parts  are  devoid  of  feeling. 
Iridectomy  has  also  been  employed  in  cases  in  which  total  blindness 
is  threatened. 

The  lesions  of  the  nose,  mouth,  and  throat,  the  secretions  from 
which  emit  a  most  offensive  odor,  especiallj^  in  the  ulcerative  stage, 
and  are  most  deleterious  to  the  patient  from  being  constantly  swal- 
lowed, should  be  treated  with  medicated  sprays,  antiseptic  douches, 
or  caustics.  For  the  purpose  of  destroying  leprous  lesions  of  the 
nasal  fossae  and  of  the  buccopharyngeal  cavity  the  thermo-  or  gal- 
vanocautery  will  be  found  most  available.  In  the  local  treatment  of 
leprosy  of  the  upper  air  and  food  passages  all  the  resources  of  the 
rhinologist  and  laryngologist  should  be  brought  into  requisition — 
cauterizations,  irrigations,  insufflations  of  liquids  or  powders  which 
are  emplo\'ed  in  the  special  treatment  of  affections  of  these  parts. 
Tracheotomy  has  been  repeatedly  performed  for  dysphagia  and  ste- 
nosis of  the  larynx,  due  to  invasion  of  leprous  neoplasms.     In  Nor- 


HYGIENIC  TREATMENT.  599 

way,  Abraliam  observed  one  patient  who  had  worn  a  tube  for  three 
years,  another  for  seven  years,  and  another  for  ten  years.  In  other 
cases  the  larynx  had  become  functionally  useful  and  the  tubes  were 
discarded. 

Hygienic  Treatment. 

Among  the  means  which  experience  has  shown  to  influence  most 
favorably  the  course  of  leprosy  are  good  hygienic  conditions.  If  the 
interest  of  the  leper  alone  were  to  be  consulted,  his  removal  to  a 
country  where  leprosy  is  not  endemic  would  be  recommended.  The 
most  favorable  conditions  comprise  residence  in  a  temperate  climate, 
well-ventilated  rooms,  freedom  from  exposure  to  damp  and  cold,  care 
of  the  skin  by  frequent  warm  baths,  massage,  warm  woollen  cloth- 
ing, exercise  in  the  open  air,  and  an  abundance  of  nutritious  food, 
fresh  meat,  vegetables,  milk,  etc.  Baths  should  be  especially  insisted 
upon  in  the  ulcerative  period,  followed  by  emollient,  soothing  oint- 
ments, since  on  account  of  the  suppression  of  the  functions  of  the 
cutaneous  glands  the  skin  becomes  dry,  fissured,  and  covered  with 
the  products  of  the  suppurative  lesions. 

Since  traumatisms  and  injuries  are  often  the  starting-points  of 
obstinate  and  destructive  ulcerations,  we  should  carefully  guard  against 
all  exposure  to  external  causes  of  irritation  and  wounds  of  the  in- 
teguments. The  eyes  should  be  protected  from  contact  of  dust  and 
other  irritant  particles. 

The  individual  capacity  of  resistance  should  be  strengthened  by 
all  measures  calculated  to  build  up  and  maintain  the  general  health 
at  the  highest  possible  standard. 

Geneeal  Conclusions. 

The  following  conclusions  may  be  formulated  as  embodying  the 
author's  views  upon  treatment: 

Leprosy  is  in  the  vast  majority  of  cases  an  incurable  disease. 

There  is  no  substance  known  to  science  which,  introduced  into 
the  body,  is  capable  of  destroying  the  bacilli  without  destroying  the 
living  cells  which  contain  them. 

Furthermore,  from  the  nature  of  the  pathological  changes  and  the 
position  of  the  baciUi  in  the  deeper  tissues,  it  is  evident  that  no  ger- 
micidal agent  can  be  brought  into  direct  contact  with  the  pathogenic 
organisms,  and  hence  all  treatment  which  has  for  its  object  the  de- 
struction of  the  bacilli  is  impossible  of  application. 

The  treatment  of  leprosy  has  been  essentially  empirical ;  whether, 
as  has  been  claimed,  certain  remedies  act  by  virtue  of  their  sterilizing 


600  MORROW — LEPROSY. 

properties  upon  the  living  tissues,  rendering  them  unsuitable  to  tlie 
growth  and  multiplication  of  the  bacilli,  cannot  be  determined. 

The  special  remedies  which  clinical  exi)erience  would  indicate  to 
be  of  the  most  value  are  chaulmoogra  oil,  gurjun  oil,  and  certain 
agents  of  the  Strychuos  family ;  all  are,  however,  more  or  less  disap- 
pointing in  their  results. 

All  observers  agree  that  in  advanced  cases,  when  general  dissemi- 
nation of  the  bacilli  has  taken  place,  curative  treatment  is  absolutely 
futile.  The  most  favorable  conditions  are  that  treatment  be  instituted 
early,  and  that  it  be  prosecuted  actively  and  energeticallj^  during  a 
prolonged  period. 

The  serum  therapy  of  leprosy,  by  the  injection  of  the  Carrasquilla 
serum  and  other  antileprotic  serums,  has  not  fulfilled  the  exj^ectations 
of  its  value.  In  the  hands  of  numerous  experimenters  its  use  has 
been  condemned  by  its  clinical  results. 

The  treatment  of  leprosy  bj'  injections  of  tuberculin  has  been 
disappointing  in  its  results.  Experiment  has  shown  that  the  action 
of  tuberculin  is  positiveh'  pernicious  in  setting  free  the  bacilli  in 
the  tissues  and  determining  the  development  of  new  foci  of  the 
disease. 

The  more  or  less  rapid  development  of  leprosy  depends  upon  the 
resistance  of  the  tissues  to  the  inroads  of  the  bacilli.  In  exceptional 
but  well-authenticated  cases,  this  capacity  of  resistance  is  sufiicient  to 
dominate  and  destroy  the  pathogenic  microbes,  as  shown  by  the 
observation  of  abortive  cases  in  which  indubitable  signs  of  the  dis- 
ease definitely  disappear  and  never  recur. 

This  capacity  of  resistance  may  be  strengthened  by  change  of  cli- 
mate, improved  habits  of  living,  and  measures  calculated  to  build  up 
and  maintain  the  general  health  at  the  highest  standard. 

Observation  shows  that  the  removal  of  a  leper  from  an  infected  dis- 
trict to  a  more  favored  climate  exerts  a  marked  modification  uj)on  the 
course  of  the  disease ;  tliere  is,  for  a  time  at  least,  an  arrest  or  retro- 
gression of  the  symptoms.  This  lull  in  the  manifestations  is,  as  a 
rule,  disajjpoiutiug  in  its  duration.  Of  the  one  hundred  and  sixty- 
eight  Norwegian  lepers  who  have  emigrated  to  this  couutrj-,  there  is 
no  record  of  a  single  definite  cure. 

A  dry,  moderately  cool,  mountain  atmosphere  is  most  favorable  in 
its  influence  upon  the  disease.  A  hot  moist  climate,  or  a  damj)  cold 
climate  are  both  unfavorable. 

A  nutritious  diet  of  fresh  meat  and  vegetables,  warm  clothing,  ex- 
ercise in  the  open  air,  and  freedom  from  exposure  to  damp  and  cold, 
are  important  elements  in  the  hygienic  course  of  treatment. 

The  care  of  the  skin  by  frequent  hot  baths,  massage,  with  inunc- 


PROPHYLAXIS.  601 

tions  of  oils,  etc.,  should  receive  as  much  attention  as  the  constitu- 
tional treatment. 

The  surgical  treatment  of  leprous  sores,  necrosed  bones,  perforat- 
ing ulcers,  the  excision  of  tubercles,  amputation  of  the  members, 
tracheotomy,  various  delicate  operations  about  the  eye,  nerve-stretch- 
ing for  the  relief  of  pain,  and  the  removal  of  threatening  complica- 
tions are  of  the  most  signal  benefit. 

Finally,  we  may  conclude  that  while  medical  science  holds  out  no 
definite  promise  of  cure  to  the  leper,  its  resources  are  sufficient  to 
arrest  or  retard  the  progress  of  his  disease,  to  promote  his  comfort, 
and  to  prolong  his  life. 

PROPHYLAXIS. 

In  dealing  with  diseases  which  are  confessedly  beyond  our  thera- 
peutic resources  prophylactic  measures  become  magnified  in  imijor- 
tance.  In  the  case  of  leprosy  the  uniform  failure  of  all  specific 
curative  treatment  which  has  been  thus  far  instituted  gives  an  added 
promineuce  to  the  value  of  preventive  treatment. 

Within  recent  times  the  prevention  of  the  spread  of  leprosy  has 
become  a  question  of  live  practical'  interest  to  our  sanitary  authori- 
ties. The  development  of  new  epidemic  and  endemic  centres  of  the 
disease  in  various  countries  previously  exempt,  its  reawakening  into 
activitj^  in  countries  where  it  was  supjDOsed  to  have  become  extinct, 
and  its  undoubted  spread  in  many  parts  of  the  world  have  stimulated 
a  renewed  interest  in  its  study,  especially  of  the  sanitary  measures 
best  adapted  for  its  suppression  or  control.  The  principal  object  of 
the  convocation  of  the  International  Congress  of  Leprologists  which 
convened  in  Berlin  in  October,  1897,  as  set  forth  in  the  call,  was  "  to 
consider  the  best  means  for  the  entire  suppression  of  leprosy."  The 
motive  of  the  call  was  stated  to  be  the  "  danger  of  a  new  pandemic 
outbreak  of  leprosy  on  the  European  continent."  While  a  convic- 
tion of  the  imminence  of  such  danger  is  not  shared  by  the  writer,  it 
must  be  admitted  that  with  the  beginning  of  the  twentieth  century 
both  Europe  and  the  United  States  are  confronted  with  conditions 
which  may  render  leprosy  a  serious  menace  to  the  public  health  of 
these  countries.     Some  of  these  conditions  may  be  briefly  referred  to. 

At  the  present  time  the  ambition  for  territorial  expansion  and  the 
desire  for  colonial  possessions  which  have  seized  upon  the  dominant 
nations  of  Europe  have  extended  to  this  country,  and  the  retention 
of  recent  territorial  acquisitions  seems  to  have  been  accepted  as  a 
settled  policy  for  the  future.  The  genius  of  modern  civilization  ap- 
pears to  be  directed  in  the  line  of  appropriating  the  territories  of 
the  older  countries,  China,  India,  Africa,  and  partitioning  them  among 


602  MORROW — LEPROSY. 

tlie  younger  and  more  aggressive  nations.  It  must  not  be  forgotten, 
however,  that,  in  ojjening  wide  the  doors  of  communication  and  inter- 
course with  these  older  semi-civilized  nations  in  which  plagues  and 
pestilences  have  been  domiciled  for  centuries,  we  are  also  brought 
closely  in  contact  with  the  diseases  to  which  thej^  are  subject.  It  is 
probable  that  many  of  our  soldiers  who  form  the  army  of  occupation 
in  Cuba,  Porto  Eico,  and  the  Philippines  will  bring  back  leprosy  as 
a  souvenir  of  their  sojourn  in  these  islands.  The  significance  of  pos- 
sible danger  to  the  health  interests  of  modern  civilized  countries  from 
this  source  has  been  recognized,  and  schools  for  the  studj-  of  tropi- 
cal diseases  have  been  established  with  the  view  of  employ  iug  the 
means  and  appliances  of  scientific  medicine  in  their  study,  and  utiliz- 
ing the  resources  of  modern  sanitary  science  in  their  prevention  and 
cure. 

In  addition  to  the  enlarged  facilities  for  rapid  communication  and 
intercourse  between  the  peoples  of  different  countries,  the  opening 
up  of  trade  and  commerce,  and  the  creation  of  new  business  and  in- 
dustrial enterj) rises,  the  commercial  proximity  thus  established  tends 
to  bring  infected  and  non-infected  races  into  closer  and  more  inti- 
mate relations.  Our  extensive  maritime  relations  with  other  coun- 
tries in  which  leprosy  is  endemic  will  enable  leper  subjects  to  find 
ready  transportation  to  our  shores,  and  there  is  every  reason  to  fear 
that  leprosy  may  eventually  come  to  be  one  of  our  current  maladies. 
The  only  question  is  whether  leprosy  can  survive  the  contact  of  civil- 
ization; whether  the  better  stamina  of  the  people,  the  improved 
hygiene  public  and  i)rivate,  and  our  modern  methods  of  sanitary 
supervision  will  be  sufficiently  strong  to  cope  with  the  disease. 

It  is  a  fact  worthj^  of  consideration  that  the  colonies  of  every 
European  country,  with  scarcely  an  exception,  are  infected  with 
leproSy,  and  the  same  may  be  said  of  the  recent  territorial  acquisi- 
tions of  this  country.  The  United  States  in  annexing  Hawaii  has 
incorporated  a  native  population  tainted  with  leprosy.  In  absorbing 
Porto  Rico,  and  in  establishing  a  protectorate  over  Cuba,  our  people 
have  been  brought  into  most  intimate  commercial  and  social  relations 
with  the  leprous  inhabitants  of  these  countries.  In  appropriating 
the  Philippine  Islands  we  have  become  possessed  of  one  of  the  most 
important  centres  of  leprosy  in  the  far  East,  and  which,  from  its 
proximity  to  the  "Cradle  of  Leprosy,"  in  Kwang-Tung  and  Hong- 
Kong,  must  be  exposed  to  continued  invasion  of  fresh  increments  of 
infected  material  in  the  Chinese  coolie  lepers.  It  is  probable  also 
that  Japan  will  furnish  a  contingent  of  leprous  immigrants  from 
among  its  overcrowded  and  non-productive  population.  The  danger 
will  probably  be  not  so  much  from  the  importation  of  native  leper 


PEOPHYLAXIS.     •  603 

immigrants  from  these  colonies,  but  from  the  exposure  of  our  own 
people,  who  will  be  attracted  by  considerations  of  trade  or  commerce, 
to  contact  with  the  leper  population.  The  lepers  that  have  recruited 
European  countries  in  the  present  century  have  been  almost  without 
exception  sailors,  soldiers,  or  official  representatives  of  the  administra- 
tive departments  who  have  sojourned  for  a  longer  or  shorter  period 
in  the  leper  colonies.  In  throwing  wide  open  the  portals  of  commu- 
nication between  our  own  and  leprous  countries  we  are  virtually  re- 
leasing the  diseases  which  had  been  secluded  behind  the  closed  doors 
of  caste  and  insular  prejudice  for  ages.  These  facts  have  a  most  im- 
portant bearing  upon  the  prophylaxis  of  leprosy. 

In  the  study  of  the  prophylaxis  of  leprosy  the  teachings  of  the 
observation  and  experience  of  other  countries  and  other  ages  should 
be  utilized.  First  in  point  of  antiquity,  as  well  as  of  extensive  experi- 
mentation, may  be  considered  the  isolation  or  segregation  of  lepers. 
In  appreciating  the  value  of  this  method  and  its  adaj^tation  to  the 
conditions  of  the  leprosy  problem  as  it  presents  itself  at  the  jjresent 
day,  we  may  inquire  into  its  utility  as  a  prophylactic  measure  applied 
to  diseases  in  general  and  the  practical  results  of  its  application  to 
leprosy  in  particular. 

The  separation  of  the  sick  from  the  well  as  a  means  of  preventing 
the  spread  of  disease  is  based  upon  science  and  common  sense,  and 
has  been  sanctioned  by  the  results  of  experience  in  all  ages.  So  far 
as  any  sanitary  procedure  can  be  regarded  as  inspired,  the  separation 
of  the  clean  from  the  unclean  may  be  considered  a  divinely  appointed 
measure  for  the  prevention  of  disease.  Leprosy  enjoys  the  distinc- 
tion of  having  been  the  first,  and  for  many  centuries  the  only,  dis- 
ease to  which  this  cardinal  principle  of  preventive  medicine  was  ap- 
plied. Indeed,  sanitary  science  may  be  said  to  have  had  its  origin  in  the 
measures  of  isolation  and  segregation  which  were  instituted  in  ancient 
times  for  the  control  of  leprosy.  While  the  wisdom  of  this  prophy- 
lactic measure  is  under  certain  conditions  unquestionable,  the  method 
of  its  practical  apjplication  in  earlier  times  cannot  be  commended. 

Under  the  Mosaic  law  it  was  rigorously  enforced  with  the  strict- 
ness with  which  punishment  is  meted  out  to  crime,  but  with  a  lack 
of  discrimination  and  humanity  which  could  be  justified  only  by 
the  semi-civilized  conditions  of  the  age.  Leprosy  was  regarded  as  a 
mark  of  divine  disfavor,  a  retribution  for  sin,  and  human  approval 
of  divine  judgment  was  shown  by  cruelty,  oppression,  and  persecu- 
tion. It  is  worthy  of  note  that  this  traditional  conception  of  the 
moral  etiology  of  leprosy  still  survives  in  certain  Oriental  countries. 
In  China,  India,  and  Japan  at  the  present  day  leprosy  is  accepted  as 
a  punishment  for  sins  committed  by  the  individual  or  by  his  ances- 


604  MORROW — LEPROSY. 

tors,  and  lepers  visit  shrines  and  lioly  places  in  expatiation  of  these 
fancied  sins.  At  a  later  period  in  Jewish  history  the  Divine  Physi- 
cian seems  to  have  shown  a  special  tenderness  and  consideration  for 
lepers,  which  markedly  contrasts  with  the  sentiment  of  hostility  and 
ostracism  that  characterized  the  spirit  of  the  old  Hebraic  law. 

For  mau}^  centuries  the  severe  and  cruel  measures  formulated  in 
the  Levitical  code  for  the  repression  of  leprosy  were  preserved  and 
l^erpetuated.  In  the  Middle  Ages,  when  Europe  was  overrun  with 
the  plague  of  leprosy,  the  regulations  for  its  repression  exhibited  the 
same  spirit  of  harshness  and  persecution  as  animated  the  Jewish  law- 
givers. The  leper  was  separated  from  his  family  and  friends,  his 
marriage  was  annulled,  his  civil  rights  were  abrogated,  and  he  was 
pronounced  legally  dead,  and  incarcerated  in  a  lazaretto  until  death 
should  release  him.  If  we  comi^are  these  projjhy lactic  measures  with 
those  of  barbarous  and  uncivilized  countries,  we  shall  find  that  the 
principal  difference  was  in  the  greater  sanctity  in  which  human  life 
was  held  by  the  Jews  and  Christians.  The  aboriginal  methods  were 
much  more  summary,  but  perhaps  more  merciful,  in  the  swift  ending 
of  the  patient's  suffering.  In  Africa,  Sumatra,  the  Fiji  Islands,  and 
many  other  uncivilized  countries,  the  aborigines  were  in  the  habit 
of  privately  killing  lepers  and  burning  their  bodies. 

If  we  contrast  the  ancient  methods  of  dealing  with  leprosy  with 
those  practised  in  modern  times,  it  is  evident  that  the  tendency  is 
towards  a  more  intelligent  and  humane  treatment  of  lepers,  although 
the  traditional  spirit  of  intolerance,  ostracism,  and  persecution  still 
survives  in  many  countries. 

The  chaotic  confusion  of  skin  diseases  has  been  cleared  up,  and, 
thanks  to  our  greater  precision  of  diagnosis,  it  is  exceptional  for  other 
forms  of  disease  to  be  confounded  with  leprosy.  Again,  under  the 
sanitary  policy  of  many  enlightened  governments  proscriptive  meas- 
ures are  now  enforced  not  only  with  a  more  intelligent  discrimina- 
tion, but  also  with  more  humanity. 

So  far  as  we  know,  leprosy  was  the  only  disease  to  which  segrega- 
tion was  applied  in  earlier  times.  In  modern  times  the  principle  has 
been  extended  in  its  application  to  a  large  group  of  diseases  which 
come  within  the  category  of  contagious  or  infections  diseases.  At 
the  same  time  there  are  certain  other  diseases  of  a  recognized  conta- 
gious nature  which  do  not  come  within  the  provisions  of  compulsory 
notification  and  isolation;  for  example,  varicella  is  not  isolated, 
although  equally  contagious  with  smallpox,  because  it  is  a  mild  dis- 
ease and  not  a  cause  of  death. 

The  isolation  of  venereal  diseases  is  not  regarded  as  feasible  or 
practicable,  largely  because  they  are  private  or  secret,  and  the  risk  to 


PROPHYLAXIS.  605 

others  of  contagion  is  chiefly  clue  to  the  voluntary  exposure  of  the 
healthy  to  contact  with  the  diseased.  Syphilis  is  perhaps  an  excep- 
tion, although  the  cases  of  syphilis  insontium  are  comparatively  few. 
In  regard  to  these  diseases,  it  is  admitted  that  they  may  be  severe  in 
their  effects,  both  immediate  and  remote;  they  entail  suffering  and 
may  endanger  life ;  they  have  an  important  socio-economic  relation  to 
the  public  health  so  far  as  their  incapacitating  effect  upon  wage-earn- 
ers, army  and  navy  invalidism,  etc.,  is  concerned,  and  also  in  their 
undoubted  influence  as  a  factor  in  the  depopulation  of  countries.  The 
individual  liberty  of  these  diseases  is  protected  by  their  nature,  their 
secrecy,  and  furthermore,  perhaps,  by  the  failure  of  all  measures  hith- 
erto proposed  for  their  correction. 

Tuberculosis,  the  modern  Samson  among  diseases,  which  slays 
its  tens  of  thousands,  while  smallpox,  measles,  scarlatina,  etc.,  slay 
their  hundreds  or  thousands,  is  recognized  as  a  contagious  and  infec- 
tious disease,  yet  modern  sanitary  science  has  not  placed  it  under  the 
ban  of  notifiable  diseases.  This  is  because  of  its  widespread  preva- 
lence, the  impossibility  of  isolating  and  supporting  the  great  -army 
of  consumptives,  and  the  fear  of  infringing  upon  the  rights  of  the 
individual;  again,  because  of  its  chronicity.  Isolation  contemplates 
brevity,  and  finds  its  proper  application  in  diseases  which  are  of 
short  duration,  and  render  the  patient  temporarily  unable  to  care  for 
himself.  But  a  consumptive  may  not  be  incapacitated  for  business ; 
he  may  have  years  of  usefulness  and  life  before  him.  The  disease 
does  not  place  him  liors  du  combat  in  the  battle  of  life.  Indeed,  he 
may  hope  for  a  comparative  or  even  complete  cure.  Sanitary  science 
cannot  attack  or  apprehend  him  in  these  strongholds.  The  result  is 
that  the  sanitary  supervision  of  tuberculosis  is  restricted  to  the  disin- 
fection or  destruction  so  far  as  practicable  of  the  sputa  containing  the 
disease  germs,  the  education  of  the  patient  as  to  the  risk  he  carries 
to  others  and  the  best  means  to  avoid  those  risks,  and  the  establish- 
ment of  sanatoria  in  favored  regions  for  the  cure  or  amelioration  of 
the  disease. 

In  leprosy  we  have  a  disease  which  presents  many  analogies  with 
tuberculosis.  As  has  already  been  said,  there  is  no  infectious  disease 
so  mild  in  its  initial  manifestations  as  leprosy.  There  is  no  disease 
of  a  necessarily  fatal  character  which  grants  its  victim  so  long  a  lease 
of  life ;  even  after  characteristic  evidences  of  the  disease  are  manifest 
the  patient  may  live  in  comparative  health  for  many  years,  with  fac- 
ulties unimpaired,  and  the  capacity  for  usefulness  and  work  practically 
undiminished.  This  is  especially  true  of  anaesthetic  cases.  It  may 
be  questioned  whether  it  is  just,  humane,  or  necessary  for  the  protec- 
tion of  society  in  countries  where  leprosy  does  not  seriously  menace 


606  MORROW — LEPROSY. 

the  public  health  to  incarcerate  such  a  person  iu  a  lazaretto  until 
death  releases  him. 

It  will  be  seen  that  mere  isolation  of  the  sick  by  no  means  repre- 
sents the  highest  wisdom  of  sanitary  science  or  the  perfection  of  sani- 
tary methods.  The  diseases  to  which  it  is  api:)licable  are  to  be  differ- 
entiated, not  only  from  the  point  of  view  of  their  gravity,  but  from 
that  of  their  prevalence  and  their  tendency  to  propagate  themselves, 
and  it  is  to  be  adapted  to  the  peculiarities  of  each  particular  disease. 
The  science  of  modern  preventive  medicine  takes  into  account,  not 
only  the  nature  and  contagiousness  of  a  disease,  but  also  the  degree 
of  its  contagioiis  activity  and  the  conditions  under  which  this  conta- 
gion operates.  The  behavior  of  the  disease  as  modified  by  these  con- 
ditions, and  its  epidemic,  endemic,  or  sporadic  character  are  to  be 
considered  in  determining  the  character  of  the  sanitary  measures  to 
be  employed  for  its  control.  Each  disease  must  be  studied  tn  relation 
to  its  environment,  the  character  of  the  soil,  and  the  conditions  which 
favor  or  lessen  its  tendency  to  spread.  We  do  not  apply,  nor  do  we 
deem"  necessary,  the  same  sanitary  regulations  for  yellow  fever  iu  New 
York  or  the  City  of  Mexico  as  for  the  same  disease  in  Havana  or 
Vera  Cruz,  because  the  conditions  which  favor  its  si)read  exist  in  the 
two  latter  cities,  but  not  iu  the  former. 

Leprosy  does  not  comport  itself  as  a  contagious  disease  under  all 
conditions  of  environment.  Its  contagious  mode  is  a  law  unto  itself. 
It  shows  the  most  remarkable  variations  in  its  virulence  and  in  its 
development  and  decline.  In  some  countries  its  contagious  viru- 
lence is  manifest  with  all  the  characteristics  of  a  violent  epidemic. 
In  other  countries  its  contagiousness  is  mild,  scarcely  manifest.  It 
is  an  error  to  suppose  that  in  all  countries  where  leprosy  is  intro- 
duced it  will  necessarily  spread,  or  that  every  leper  will  communicate 
his  disease  to  those  with  whom  he  comes  in  contact.  It  is  equally 
erroneous  to  conclude  that  we  possess  in  segregation  or  isolation  an 
infallible  or  sure  cure  for  the  prevention  of  leprosy,  or  that  these 
measures  employed  in  the  most  active,  energetic,  and  vigorous  man- 
ner will  infallibly  cut  short  its  epidemic  violence.  It  may  be  claimed 
that  segregation  constitutes  the  best  means  known  to  sanitary  science 
for  the  prevention  of  leprosy,  but  the  indications  for  its  employment 
are  to  be  differentiated  and  adapted  according  to  the  manifestations 
of  its  contagious  power  in  different  countries  and  the  degree  of  their 
leprous  contamination. 

We  may  now  inquire  what  has  been  the  practical  result  of  segre- 
gation in  certain  countries  where  it  has  been  applied.  The  success- 
ful results  of  segregation  are  claimed  to  have  been  most  brilliantly 
illustrated  in  the  extinction  of  the  leprosy  epidemic  of  the  Middle 


PKOPHYLAXIS.  607 

Ages,  and  in  more  recent  times  in  the  marked  decline  of  the  Norway 
epidemic  It  may  be  observed  that  a  great  many  intelligent  and  judi- 
cious students  of  the  history  of  leprosy  insist  that  the  cause  of  the 
progressive  diminution  of  the  disease  in  the  fourteenth  and  fifteenth 
centuries  and  of  its  practical  disappearance  from  Europe  in  the  six- 
teenth and  seventeenth  centuries  was  not  due  to  the  admittedly  im- 
perfect system  of  segregation  then  employed,  but  should  rather  be 
ascribed  to  the  improvement  in  the  material  hygienic  and  social  con- 
ditions of  the  people ;  to  the  better  food,  better  habitations,  and  the 
increase  in  material  prosperity.  In  the  Middle  Ages  strict  segrega- 
tion, if  we  are  to  trust  historical  evidence,  was  never  carried  out. 

Newman,  in  his  prize  essay  on  "  The  History  of  the  Decline  and 
Final  Extinction  of  Leprosy  as  an  Endemic  Disease  in  the  British 
Islands"  (New  Sydenham  Society,  1895),  believes  that' probably  the 
famine  (1315)  and  black  death  (1349)  materially  assisted  in  the  exter- 
mination of  lepers  in  the  fourteenth  century.  He  believes  that  the 
decline  and  final  extinction  of  endemic  leprosy  was  due  not  to  segre- 
gation, but  to  the  general  and  extensive  social  improvement  in  the  life 
of  the  people  and  to  a  complete  change  in  the  poor  and  insufficient 
diet,  the  agricultural  advancement,  improved  sanitary  and  land  drain- 
age, etc. 

Jonathan  Hutchinson  is  also  inclined  to  the  belief  that  segrega- 
tion exerted  little  influence  in  the  decline  of  the  mediaeval  epidemic, 
but  that  it  took  place  by  slow  degrees  pari  passu  with  the  advance  of 
agriculture  and  in  social  comfort. 

As  regards  the  decrease  of  leprosy  in  Norway,  it  may  be  said  that 
no  effective  system  of  isolation  or  segregation  worthy  the  name  has 
ever  been  carried  out  in  that  country.  Before  1885  the  lepers,  except 
a  limited  number  who  were  unable  to  provide  for  themselves,  did  not 
enter  the  hospitals.  Entrance  into  the  leprosy  hospitals  was  volun- 
tary, not  compulsory,  and  lepers  were  free  to  come  and  go.  More- 
over, leprosy  had  already  begun  to  decrease  before  1885,  at  which 
date  the  leprosy  law  was  enacted  which  made  entrance  into  the  hos- 
pital compulsory  for  paupers  who  could  not  provide  for  their  own 
wants.  "The  leper,  if  he  will  live  at  home,  must  have  his  own 
room,  at  least  his  own  bed,  his  clothes  must  be  washed  separately, 
he  must  have  his  own  eating  apparatus- — spoon,  knife,  fork,  etc.  If 
he  cannot  or  will  not  comply  with  this  regime,  he  is  obliged  to  enter 
an  asylum." 

It  is  generally  conceded  that  the  leprosy  laws  of  Hawaii  are  more 
complete  and  rigorous  and  are  enforced  with  more  strictness  and  im- 
partiality than  in  any  country  in  the  world.  Segregation  has  been 
practised  for  over  a  third  of  a  century  in  these  islands  with  a  vigor 


608  MORROW — LEPROSY, 

and  severity  whicli  would  not  be  possible  among  a  people  who  were 
jealous  of  their  personal  rights  or  individual  liberty-.  What  has  been 
the  result  of  this  thirty-five  years'  crusade  against  leprosy?  Is  it  on 
the  increase,  or  is  it  in  process  of  extermination?  Taking  the  rec- 
ords of  the  leper  settlement  as  a  basis  of  comparison,  there  would 
seem  to  be  no  favorable  sign  of  its  extinction.  In  the  first  twenty 
years  of  its  establishment  3,076  lepers,  in  the  next  ten  years  2,049 
were  consigned  to  the  leper  settlement.  This  large  relative  increase 
of  admissions,  it  is  claimed,  may  be  due  not  to  an  actual  increase  in 
the  number  of  lepers  in  the  islands,  but  to  a  more  active  and  vigorous 
method  of  segregation  within  the  last  ten  years.  In  the  first-men- 
tioned period  the  number  of  lepers  at  the  settlement  ranged  from  two 
hundred  to  eight  hundred.  In  recent  j'ears  the  number  has  varied 
from  one  thousand  to  twelve  hundred,  and  the  annual  consignment  of 
lepers  shows  little  diminution  in  number  from  year  to  year. 

Segregation  must  always  be  a  defective  measure  from  the  very 
nature  of  the  disease,  simply  because  all  cases  of  leprosy  cannot  be 
brought  within  the  sphere  of  its  oi^eration.  No  official  dragnet  can 
ever  be  constructed  which  will  gather  up  all  the  lepers  in  any  countr}'. 
The  little  fishes,  the  latent,  incipient  lepers  will  escape.  Segrega- 
tion, although  incomplete,  undoubtedly  tends  to  limit  the  spread  of 
the  disease  by  removing  or  rendering  innocuous  just  so  many  sources 
of  contagion. 

Experience  teaches  us  that  harsh  measures  of  isolation  and  segre- 
gation always  defeat  the  object  in  view  because  their  chief  result  is 
the  concealment  of  cases.  Unless  human  nature  changes,  the  more 
rigorous  and  severe  the  measures  adopted  the  greater  will  be  the 
incentive  to  evade  and  escape  their  operation,  no  matter  how  benefi- 
cent their  purpose.  In  South  Africa  the  recent  leprosy  commission 
came  to  the  conclusion  that  the  attempt  to  send  all  lepers  to  Robben 
Island  only  led  to  many  lepers  being  hidden  throughout  the  country. 
In  the  Berlin  Leprosy  Congress  Alvarez  of  Honolulu  declared  his  "  op- 
position to  the  adoption  of  rigorous  or  cruel  measures  against  leprosy 
in  Hawaii,  not  only  because  they  led  to  the  concealment  of  cases, 
and  thus  defeated  the  object  for  which  they  are  designed,  but  because 
we  ought  to  adhere  to  principles  of  humanity  and  not  treat  the  lepers 
as  if  they  were  criminals." 

Similar  results  from  the  operation  of  strict  segregation  laws  have 
been  observed  in  all  countries  where  an  attempt  has  been  made  to 
enforce  them. 

While  allowing  segregation  to  be  the  most  effective  measure  known 
to  sanitary  science  for  the  prevention  of  leprosy,  its  application  is  not 
universally  practicable.     In  India  segregation  is  not  practicable  be- 


PROPHYLAXIS.  609 

cause  of  tlie  number  of  lepers.  Any  government  would  stand  appalled 
and  helpless  before  the  task  of  segregating  and  supporting  more  than 
one  hundred  thousand  individuals.  The  same  consideration  applies 
to  leprosy  in  China  and  Japan. 

Again,  the  social  and  political  conditions  in  different  countries 
must  be  considered  in  applying  measures  vrhich  infringe  upon  per- 
sonal liberty.  Serious  difficulty  -was  met  with  in  India  recently  in 
endeavoring  to  induce  the  people  to  adopt  simple  sanitary  precautions 
against  the  plague,  an  acute  and  fatal  disease.  One  may  appreciate 
the  difficulties  to  be  surmounted  in  instituting  harsh  measures  against 
a  disease  which  has  existed  in  piermanence  among  them  from 'time 
immemorial. 

It  must  be  remembered  that  in  old  countries  where  leprosy  has 
existed  for  centuries  there  are  deep-rooted  customs  which  seem  al- 
most as  sacred  as  religious  observances  and  which  have  all  the  force 
of  unwritten  laws ;  these  customs  cannot  be  eradicated  without  oppo- 
sition or  open  revolt.  It  is  not  possible  for  anj-  government  by  com- 
pulsory laws  to  compel  such  people  to  have  recourse  to  national  estab- 
lishments for  isolation  and  treatment. 

It  was  with  a  full  knowledge  of  these  facts  that  the  Berlin  Leprosy 
Congress  unanimously  adopted  the  following  resolutions  as  embracing 
the  views  of  the  congress  upon  the  best  means  to  be  employed  for  the 
control  and  suppression  of  leprosy. 

First,  in  such  countries  where  leprosy  is  endemic,  and  in  all  coun- 
tries where  leprosy  forms  foci  or  has  a  great  extension,  isolation  is 
the  best  means  of  preventing  the  spread  of  the  disease. 

Second,  the  system  of  obligatory  notification  and  surveillance  and 
isolation,  as  practised  in  Norway,  should  be  recommended  to  all 
nations  with  local  self-government  and  a  su:fficient  number  of  physi- 
cians. 

Third,  it  should  be  left  to  the  administrative  authorities  after  con- 
sultation with  the  medical  authorities  to  take  such  measures  as  are 
applicable  to  the  special  social  conditions  in  each  country. 

These  recommendations  seem  eminently  wise  and  judicious  and 
coincide  for  the  most  part  with  the  views  expressed  by  the  writer  sev- 
eral years  ago.  As  regards  "obligatory  notification,"  it  may  be  said 
that  the  wisdom  of  a  measure  which  renders  it  obligatory  on  the 
part  of  physicians  to  report  to  the  sanitary  authorities  every  case  of 
leprosy  coming  under  their  observation  is  questionable  in  countries 
when  leprosy  does  not  prevail  to  an  alarming  extent.  In  coun- 
tries where  segregation  is  compulsory,  notification  is,  of  course, 
necessary  to  the  effectiveness  and  success  of  the  scheme.  In  this 
country  it  might  serve  to  locate  a  few  cases  of  leprosy  unknown  to  the 
Vol.  XVIII. —39 


610  MORROW— LEPROSY. 

authorities,  but  unless  they  are  empowered  to  isolate  such  cases  they 
could  exercise  over  them  only  a  sort  of  sanitary  surveillance  of  doubt- 
ful utility,  and  which,  if  oppressive,  would  result  in  the  migration  of 
the  leper  to  another  locality.  The  action  of  the  Philadelphia  board 
of  health  a  few  years  ago  in  fining  a  physician  for  not  reportiug  two 
cases  of  leprosy  under  his  care  was  generally  condemned  by  the  med- 
ical profession. 

Another  aspect  of  the  question  is  worthy  of  consideration.  In 
countries  where  lepros\'  is  not  endemic  few  jjhysicians  have  ever  seen 
a  case.  They  are  not  familiar  with  the  clinical  features  of  the  dis- 
ease and  are  therefore  uot  competent  to  make  a  diagnosis.  The  ver- 
dict of  leprosy  carries  with  it  a  grave  responsibility,  and  should  never 
be  pronounced,  or  at  least  accepted,  as  final  unless  confirmed  by  a 
special  board  of  competent  experts.  The  consequences  to  the  individ- 
ual are  of  such  a  serious  character  that  the  same  care  and  intelligent 
skill  should  be  exercised  as  contemplated  in  the  law  which  provides 
for  a  commission  of  lunacy  to  inquire  into  the  mental  soundness  of  an 
individual. 

One  prophylactic  measure  which  meets  with  universal  acceptance 
is  the  endeavor  to  confine  leprosy  in  countries  where  it  already  exists 
and  prevent  its  extension  in  countries  exempt  or  but  slightly  infected, 
by  the  exclusion  of  all  lejn-ous  immigrants.  As  will  be  seen  in  another 
section  of  this  article,  quarantine  laws  prohibiting  the  introduction  of 
leprous  immigrants  have  been  enacted  by  various  governments,  and 
their  strict  enforcement  guaranteed  hj  a  heavy  penalty  of  fine  or  im- 
prisonment for  violation  of  their  provisions,  but  from  the  very  nature 
of  the  disease  this  measure  is  only  partially  effective. 

As  I  wrote  several  years  ago,  "  no  system  of  quarantine  has  ever 
been  devised  which  will  effectively  prevent  the  importation  of  a  dis- 
ease so  insidious  in  its  development  or  so  little  manifest  on  ordinary 
inspection  as  leprosy." 

A  thorough  examination  for  signs  of  leprosy  would  necessitate  the 
stripping  of  the  entire  body,  so  that  every  portion  of  the  cutaneous 
surface  might  be  subjected  to  inspection — a  i)rocedure  which  for 
many  reasons  is  entirely  impracticable. 

Hansen  says :  "  I  have  been  given  the  names  of  many  lepers  in 
America  whom  we  did  not  know  to  be  lepers  when  the}-  left  Norway. 
A  majority  of  them  have  got  distinct  eruptions  after  their  arrival  in 
America.  Even  after  the  most  scrupulous  examination  of  these 
people  at  the  time  of  their  departure  from  Norway  we  could  not 
have  been  able  to  diagnosticate  their  disease,  and  anj-  prohibition 
of  the  immigration  of  lepers  will  be  for  the  same  reason  useless." 
According  to  Bracken,  "  it  would  be  far  more  probable  to  say  that 


PROPHYLAXIS.  611 

twenty-five   of  the  fifty-one  lepers   had  the  disease  before   leaving 
Europe." 

That  we  are  constantly  importing  leprosy  is  a  recognized  fact. 
Quarantine  protection  could  be  made  more  effective  by  international 
cooperation  between  governments  in  which  not  only  the  leper  immi- 
grant, but  all  immigrants  coming  from  leprous  families,  should  be 
examined  before  they  embark,  and  even  if  they  show  no  signs  of 
the  disease,  they  should  be  kept  under  surveillance  for  several  years 
after  they  arrive  in  the  new  country  in  order  to  watch  for  develop- 
ments. The  good  effect  of  such  a  system  is  shown  in  the  work- 
ing of  the  international  laws  regulating  the  importation  of  Japanese 
contract  laborers  into  Hawaii.  The  Japanese  laborers  are  examined 
before  leaving  their  own  country  and  also  upon  their  arrival  in  Hawaii. 
During  the  period  in  which  these  laws  have  been  in  operation  among 
the  twenty-eight  thousand  Japanese  laborers  who  have  been  brought 
to  Hawaii  only  six  cases  of  leprosy  developed,  and  these  were  re- 
turned to  Japan. 

At  the  jn'esent  day  there  is  a  wide  difference  in  opinion  among 
leprologists  as  well  as  sanitary  authorities  respecting  the  value,  or 
rather  the  necessity,  of  employing  compulsory  segregation  for  the  sup- 
pression of  leprosy  in  this  country  and  Europe.  Some  contend  that 
such  radical  measures  constitute  the  only  effective  means  at  our  com- 
mand for  the  control  of  the  disease,  and  they  formulate  the  proposi- 
tion that  every  leper,  whenever  and  wherever  found,  should  be  at  once 
isolated  from  all  contact  with  healthy  individuals  and  that  this  com- 
pulsory isolation  should  be  enforced  by  government  edict.  It  may 
be  said  that  a  sanitary  measure  for  the  prevention  of  every  disease  is 
like  a  panacea  for  the  cure  of  all  diseases :  "  what  is  good  for  all  is 
good  for  nothing."  There  is  no  doubt  that  an  unreasoning  enthusi- 
asm often  obscures  the  judgment  and  blinds  the  critical  faculty,  so 
that  one  cannot  intelligently  decide  as  to  the  real  value  or  efficiency 
of  a  proposed  measure.  Just  as  in  the  curative  treatment  of  disease 
the  indications  vary  according  to  the  nature  and  course  of  the  indi- 
vidual disease,  so  sanitary  and  prophylactic  measures  must  be  adapted 
to  the  character  and  the  contagious  mode  of  the  particular  disease. 
They  must  be  specialized  or  individualized.  Under  certain  conditions 
an  expectant  treatment,  meeting  the  indications  as  they  arise,  is  all 
that  is  necessary.  Under  other  conditions  the  treatment  must  be 
energized.  In  other  words,  it  must  be  symptomatic  and  adapted  to 
the  peculiarities  of  the  individual  disease. 

It  is  important,  first  of  aU,  to  know  the  characteristics  and  course  of 
leprosy  in  a  community  or  country  in  order  to  appreciate  and  measure 
the  prophylactic  means  which  should  be  directed  to  its  control.     In 


612  MORROW— LEPROSY. 

dealing  with  a  disease  so  irregular  and  so  variable  in  its  contagious  ac- 
tivity, which  seems  to  differ  widely  in  different  countries  and  in  different 
epochs  under  conditions  which  we  can  neither  control  nor  comprehend, 
it  is  evident  that  we  cannot  formulate  regulations  which  are  universalh- 
applicable  to  all  countries  irrespective  of  the  behavior  of  the  disease, 
its  tendency  to  si:)read,  and  the  degree  of  their  leprous  contamination. 

In  a  country  where  leprosy  is  epidemic,  as  in  the  Sandwich  Islands, 
where  there  is  great  promiscuity  in  the  habits  of  eating  and  drinking 
and  the  mode  of  life  is  essentially  communistic,  where  the  natives  are 
too  ignorant  or  indifferent  to  observe  those  precautions  which  science 
has  indicated  as  necessarj'  to  avoid  contagion,  and  above  all  where  the 
disease  manifests  itself  with  intense  virulence,  strict  segregation  is  a 
necessary  protective  measure.  But  in  this  country,  where  tlie  habits 
of  life  are  different,  where  persons  are  non-communistic  in  the  mat- 
ters of  eating  and  drinking  and  sleeping,  and  where  observation  has 
shown  that  the  disease  has  a  tendency  to  die  out  from  natural  causes 
rather  than  to  propagate  itself,  such  harsh  measures  wotild  be  cruel 
and  inhuman,  as  they  are  unnecessary.  It  would  be  absurd  to  api)ly 
the  same  repressive  measures  for  the  control  of  leprosy  in  England 
and  France  as  in  their  colonies  in  South  Africa  and  New  Caledonia, 
where  the  natives  are  dirty  and  promiscuous  in  their  habits,  commu- 
nistic in  their  modes  of  living,  and  who  do  not  fear,  but  ignorantly 
invite  contagion. 

From  the  above  it  is  not  to  be  inferred  that  the  Avriter  is  an  oppo- 
nent of  segregation ;  on  the  contrary-,  he  believes  that  segregation  is 
the  most  effective  measure  that  can  be  employed  to  limit  the  spread 
of  leprosj",  and  in  some  countries  it  is  a  necessary'  measure ;  but  he  does 
not  believe  that  it  can  ever  result  in  the  entire  suppression  of  leprosy, 
largely  because  of  the  nature  of  the  disease  and  the  impossibility  of 
making  it  thorough  and  complete.  Upon  this  point  may  be  quoted 
the  writer's  views,  expressed  several  years  ago :  "  There  can  be  no 
doubt  that  if  every  leper  on  the  face  of  the  globe  were  removed 
from  all  contact  or  communication  wath  the  healthj-  the  disease 
would  become  extinct  with  the  death  of  the  present  leper  popu- 
lation. But  isolation  or  segregation  of  lepiers  in  special  communities 
or  hospitals,  in  order  to  be  effective,  must  be  thorough  and  complete. 
In  countries  where  the  compulsory  segregation  of  lepers  has  been 
enacted  by  legislative  authority  its  thorough  enforcement  has  been 
found  to  be  impracticable.  Even  in  the  Hawaiian  Islands,  where  the 
energies  of  the  Government  have  for  years  been  directed  to  this  end 
with  all  possible  vigor,  it  has  failed  to  accomplish  the  object.  Doubt- 
less these  measures  have  checked  the  disease,  but  the  latter  shows  no 
signs  of  extinction. 


PROPHYLAXIS.  613 

"  The  causes  of  this  failure  are  probably  due  largely-  to  the  insid- 
ious character  of  the  disease.  In  every  country  where  leprosy  is  en- 
demic a  large  number  of  persons  are  infected  months  and  years  before 
it  is  known  to  themselves  or  to  others.  Now  unless  leprosy  is  devoid 
of  contagious  activity  in  the  earlier  stages  segregation  of  this  class  is 
absolutely  essential  to  the  effectiveness  of  the  scheme.  If  such  cases 
are  contagious,  they  are  most  dangerous  since  their  intercourse  with 
family  and  friends  is  not  restricted  by  the  wholesome  disgust  which 
the  disease  in  the  later  stage  always  inspires.  Again,  manj-  lepers 
present  in  their  face  no  visible  sign  of  the  disease,  or  they  manage  to 
conceal  all  convicting  Evidence  for  many  years  after  it  has  developed. 
Such  persons  must  be  active  spreaders  of  the  contagion. 

"  In  this  country,  the  compulsory  segregation  of  lepers  in  lazaret- 
tos, as  has  been  recommended  by  some  of  our  health  authorities,  can 
scarcely  be  considered  a  necessary  protective  measure.  Wherever 
leprosy  has  been  introduced,  except  in  the  moist,  warm  climate  of  our 
Southern  seaboard  (Louisiana  and  Key  West),  it  does  not  show  an 
alarming  tendency  to  spread  and  develop  new  foci  of  infection.  Pro- 
fessional as  well  as  public  sentiment  is  ojjposed  to  the  adoption  of  harsh 
coercive  measures  to  crush  out  an  evil  which  does  not  seriously  men- 
ace the  public  health,  but  rather  tends  to  die  out  from  natural  causes." 

The  endemic  outbreak  of  leprosy  in  Louisiana,  where  the  disease 
had  been  quiescent  and  apparently  extinct  for  a  century  or  more, 
shows  conclusively  that  no  measures  for  the  control  of  leprosy  can  be 
considered  absolute  or  permanent.  They  must  be  modified  and 
adapted  to  changing  conditions  as  they  arise.  Twenty -five  years  ago 
the  necessity  of  taking  active  measures  for  the  suppression  of  leprosy 
in  that  State  would  not  have  been  considered  urgent ;  but  the  recent 
statistics  of  leprosy  in  Louisiana  show  that  the  disease  is  spreading 
and  rapidly  assuming  alarming  proportions.  This  is  only  another 
illustration  of  the  variability  in  the  contagious  activity  of  leprosy, 
which  manifests  marked  modifications  in  its  virulence  accordingly  as 
the  conditions  which  influence  its  development  and  spread  are  pres- 
ent or  absent.  In  Louisiana  an  attempt  has  been  made  to  prevent  a 
farther  spread  of  the  disease  by  the  establishment  of  a  leper  asylum, 
and  while  the  advantages  afforded  by  this  institution  have  been  ac- 
cepted by  a  limited  proportion  of  the  leper  population,  the  larger  num- 
ber of  lepers  is  still  at  large. 

In  this  country  there  is  no  possible  protection  against  the  spread 
of  leprosy  by  the  enactment  of  laws  for  the  segregation  of  lepers  by 
the  different  States.  Segregation  by  single  States  is  not  practicable. 
The  result  would  be  to  drive  lepers  from  States  enforcing  such  prac- 
tice to  States  where  segregation  was  not  practised. 


614  MORROW— LEPROSY. 

Leprosy  in  the  United  States  sliould  be  under  the  control  of  the 
national  Government.  It  in  the  opinion  of  our  sanitary  authorities 
leprosy  prevails  in  any  State  or  section  of  this  country  to  such  an 
extent  as  to  prove  a  serious  menace  to  the  public  health  and  demands 
the  segregation  of  the  few  for  the  pji'otection  of  the  many,  homes  or 
asylums  with  suitable  hygienic  surroundings  should  l)e  provided  for 
the  care  and  maintenance  of  lepers  by  the  national  Government. 
Such  asylums  should  he  made  comfortable  and  attractive  and  arranged 
with  special  adaptation  to  the  requirements  and  peculiar  needs  of  their 
inmates.  In  view  of  the  chronicity  of  the  disease,  lepers  should  not 
be  condemned  to  confinement  and  inactivity,  but  should  be  j^rovided 
with  interests,  meaus  of  employment,  and  recreation.  As  a  large 
proiDortiou  of  lepers  are  able  to  engage  in  some  kind  of  industry, 
3uch  institutions  might  be  made  partly  or  wholly  self-sustaining  from 
the  jjroceeds  of  their  industries.  They  might  be  conducted  as  colo- 
nies, and  provision  shovild  be  made  for  giving  occupation  to  those 
able  to  work. 

Many  lepers  would  doubtless  avail  themselves  of  the  advantages 
of  such  an  institution.  There  comes  a  time  in  the  history  of  almost 
every  leper  wlien  he  recognizes  himself  as  an  object  of  disgust  and 
pit}'  to  his  family  and  friends,  when  he  would  be  glad  of  an  asylum 
in  which  to  end  his  miserable  existence.  Again,  there  are  man}- 
lepers  who  would  gladly  go  to  such  a  refuge  as  soon  as  the  nature 
of  their  disease  is  evident,  for  fear  of  spreading  the  contagion  to  their 
families  or  friends. 

An  intelligent  discrimination  should  be  exercised  in  selecting  cases 
suitable  for  segregation. 

Wliile  we  know  nothing  definitely  of  the  modes  of  infection  or  the 
conditions  under  which  it  takes  place,  we  recognize  Hansen's  bacillus 
as  the  active  efficient  cause  of  leprosy.  Its  degree  of  contagiousness 
will  depend  upon  the  type  of  the  disease  and  its  stage  of  develop- 
ment. In  the  pure  type  of  anpesthetio  leprosy  the  bacilli  remain  for 
many  years  localized  in  the  nerve  tissues  and  are  not  found  in  the 
cutaneous  lesions.  Sucli  patients  are  probabl\^  exemiit  from  all  pos- 
sibilitj"  of  danger  to  others  until  at  an  advanced  stage,  wlien  the  tis- 
sues break  down  and  liberate  the  bacilli.  In  the  writer's  opinion 
such  cases  bear  much  the  same  relation  to  the  tubercular  form,  from 
the  point  of  view  of  contagion,  as  fibroid  phthisis  does  to  acute  or 
chronic  pulmonary  tuberculosis. 

Lepers  in  good  circumstances,  able  to  provide  themselves  with 
separate  homes,  and  whose  intercourse  with  the  healthy  could  be 
restricted  under  sanitary  surveillance,  should  not  be  subject  to  segre- 
gation.    Observation  shows  that  if  a  leper  lives  by  himself,  with  sep- 


PROPHYLAXIS.  615 

arate  room,  bed,  board,  etc.,  and  does  not  come  in  intimate  contact 
with  otliers,  lie  is  practically  innocuous  so  far  as  contagion  is  con- 
cerned. In  cases  in  wliicli  sucli  conditions  cannot  be  complied  with 
the  leper  should  be  placed  in  a  hospital  or  asylum  specially  provided 
for  this  class  of  patients. 

Wherever  he  may  be  placed,  the  leper  himself,  as  well  as  his  hab- 
itation, should  be  kept  scrupulously  clean.  In  view  of  the  fact  that 
contamination  probably  takes  place  chiefly  from  the  nasal  or  buccal 
excretions,  these  should  be  disinfected  or  destroyed  with  the  game 
care  that  would  be  exercised  in  cases  of  tuberculosis.  In  addition 
strict  antisei:itic  and  occlusive  dressings  should  be  ap[)lied  to  all  open 
sores  or  ulcerations.  The  garments  of  the  leper  should  be  separately 
washed,  and  his  clothes,  linen,  and  ordinary  objects  of  use  should  be 
regularly  disinfected  from  time  to  time. 

Finally,  if  lepers  are  segregated  they  should  receive  expert  med- 
ical care.  They  should  be  treated  energetically  by  all  known  means, 
external  or  internal,  sanctioned  by  experience.  There  is  no  doubt 
that  the  lamentable  failure  of  our  therapeutic  resources  is  due  largely 
to  the  conditions  under  which  they  have  been  aj^jjlied.  The  dominant 
conviction  forced  upon  lepers  when  placed  in  a  lazaretto  is  that  they 
are  shut  up  to  die,  and  the  utter  hopelessness  thus  engendered  ren- 
ders all  treatment  a  failui-e.  Says  a  well-known  writer:  "When  a 
man  affected  with  leprosy  is  taken  from  his  home  and  friends,  pro- 
nounced unclean,  immured  in  a  lazaretto  with  many  loathsome  fel- 
low-sufferers, and  given  to  understand,  as  is  usually  the  case,  that 
death  is  the  only  portal  of  escape  open  to  him,  the  impression  upon 
his  mind  is  such  as  to  counteract  the  efl'ect  of  all  remedies,  and  under 
such  circumstances  nothing  short  of  a  miracle  could  be  expected  to 
effect  a  cure  of  leprosy." 

There  is  no  doubt  that  if  sanatoriums  or  colonies  were  instituted 
for  the  reception  of  lepers,  as  in  the  case  of  tuberculosis,  and  pro- 
vided with  suitable  means  of  treatment  in  the  earliest  stages,  many 
of  the  cases  might  be  aborted  or  the  fui'ther  progress  of  the  dis- 
ease arrested.  In  view  of  the  incompleteness  of  our  knowledge  of 
leprosy  and  the  necessity  for  the  further  study  of  the  life  history  of 
the  bacillus  and  the  conditions  under  which  it  is  communicated,  a 
laboratory  under  the  care  of  an  expert  physician  should  be  estab- 
lished in  connection  with  every  such  asylum,  for  the  study  of  the  dis- 
ease with  the  aid  of  modern  technique  and  of  the  various  instruments 
of  precision. 


616  MORROW — LEPROSY. 


HISTORY. 


Leprosy  occupies  r.  peculiar  positiou  among  diseases  affecting  the 
human  race.  It  is  the  most  ancient,  the  most  exclusively  human, 
and  in  the  popular  conception  the  most  dreaded  of  all  diseases.  It 
is  a  universal  malady,  affecting  all  races  and  occurring  in  all  climates 
and  under  all  conditions  of  life.  Although  no  race  is  immune,  racial 
peculiarities,  climate,  and  the  hygienic  habits  of  civilization  undoubt- 
edly modify  its  spread. 

Unlike  the  plagues  and  pestilences  which  formerlj'  swept  a,wa,j 
entire  populations  and  devastated  countries  and  then  disappeared  for- 
ever, leprosy  has  at  certain  periods  of  the  world's  history  raged  as  a 
veritable  epidemic  and  then  subsided  and  apparently  disappeared,  but 
has  never  become  extinct.  It  has  preserved  its  individuality  through 
all  the  vicissitudes  of  time.  It  still  survives  and  maintains  its 
supremacy-  as  the  patriarch  of  diseases. 

The  origin  of  leprosy  is  lost  in  the  night  of  time.  There  are  cer- 
tain special  circumstances  which  have  made  the  study  of  the  early 
history  of  leprosy  one  of  peculiar  difficulty.  In  endeavoring  to  trace 
authentic  records  of  leprosy  in  the  earlier  writings,  we  are  confronted 
with  difficulties  which  arise  from  the  lack  of  medical  knowledge  among 
primeval  peoples,  their  conseqiient  defective  description  of  disease, 
and  their  inability  to  distinguish  the  morbid  phenomena  peculiar  to 
different  diseases.  It  could  hardh'  be  exj)ected  in  the  undeveloped 
state  of  medical  science  that  Icprosj^  or  any  other  disease  would  be 
described  with  that  accuracy  and  minuteness  of  detail  which  charac- 
terizes the  description  of  disease  of  the  present  day.  We  should 
expect  that  only  one  or  more  prominent  symptoms  of  the  disease 
which  particularly  impressed  the  observer  would  be  mentioned. 

Another  difficulty  arises  from  the  doubt  as  to  the  exact  meaning  to 
be  given  the  terms  emi:)lo3^ed  by  ancient  writers  in  designating  dis- 
eases, and  whether  the  words  in  different  languages  which  have  been 
translated  as  leprosy  actually  referred  to  the  same  or  to  different  dis- 
eases. In  the  evolutionary  changes  to  which  all  languages  are  sub- 
ject the  primary  signification  of  certain  terms  is  involved  in  obscurity, 
and  there  has  always  been  much  diversit}^  of  oi^iuion  as  to  the  iden- 
tity of  the  Hebrew  "tsaraath,"  the  Greek  "leuke,"  the  Arabian  "ba- 
ras"  with  modern  leprosy,  but,  irrespective  of  all  these  elements  of 
confusion,  the  fact  remains  that  from  the  earliest  attempts  to  record 
the  phenomena  of  disease  there  may  be  traced,  through  the  succes- 
sion of  centuries,  in  the  Greek,  Arabian,  and  Roman  writings,  an 
unbroken  reference  to  a  particular  disease,  which  stands  prominent!}" 


HISTORY.  (;17 

forth  among  other  diseases,  and  which  powerfully  impressed  the  pop- 
ular imagination  by  its  severity,  its  hideous  deformity,  and  its  incur- 
ability, and  which  we  recognize  as  leprosy.  It  is  equally  certain  that 
many  milder  forms  of  disease,  which  present  one  or  more  symptoms 
in  common  with  this  more  formidable  disease,  were  included  in  the 
category  of  leprosy.  This  diagnostic  error  has  been  perpetuated 
through  mediaeval  times  and  is  still  committed  at  the  present  day. 

In  the  Middle  Ages  the  diagnosis  of  leprosy  was  still  in  a  state  of 
chaotic  confusion,  and  in  the  leproseries  were  found  numerous  exam- 
ples of  almost  every  form  of  cutaneous  disease.  Even  in  countries 
where  leprosy  is  now  endemic  the  result  of  the  examination  of  sup- 
posed cases  of  the  disease  by  presumably  skilled  and  competent  phy- 
sicians shows  patients  in  whom  the  symptoms  are  suspicious  but  by 
no  means  conclusive. 

Although  leprosy  has  existed  in  all  periods  of  the  world's  history 
and  afforded  abundant  opportunities  for  its  observation  and  study,  it 
is  the  reproach  of  medical  science  that,  in  some  respects,  it  is  to-day 
the  most  mysterious  and  obscure  of  all  diseases,  especially  in  its 
modes  of  communication,  its  variable  virulence,  and  its  faculty  of 
remaining  latent  for  a  long  period  and  then  reawakening  into  activity. 

In  explanation  of  this  lack  of  definite  knowledge  of  the  disease  it 
may  be  said  that  for  several  centuries  leprosy  had  practically  dis- 
appeared from  Europe  and  other  civilized  countries  where  medical 
'science  was  most  cultivated  and  where  the  capacity  of  intelligently 
studying  and  classifying  diseases  was  most  trained  and  developed. 
During  the  seventeenth,  eighteenth,  and  the  first  half  of  the  nine- 
teenth centuries  leprosy  had  for  the  medical  profession  only  a  histori- 
cal interest.  When  an  important  leprous  centre  was  discovered  in 
Norway  about  fifty  years  ago,  it  was  a  revelation  and  a  surprise,  and 
leprosy  became  invested  with  all  the  interest  of  a  resurrected  disease. 

Prior  to  the  appearance  of  the  magisterial  work  of  Daniellsen  and 
Boeck  on  leprosy,  in  1848,  the  communications  in  regard  to  tbe  dis- 
ease were  of  a  vague  and  incomplete  character,  possessing  little  scien- 
tific value  and  not  generally  accessible.  It  may  be  said  that  the  first 
opportunity  of  studying  the  disease  by  the  methods  of  modern  sci- 
ence was  afforded  by  the  Norwegian  epidemic,  which  has  been  termed 
the  "academy  of  instruction,"  in  leprosy.  The  epidemic  gave  a  new 
interest  to  the  study  of  the  disease  by  scientific  men.  Its  survival  or 
reappearance  in  many  civilized  countries  from  which  it  was  thought 
to  have  definitely  disappeared  and  its  undoubted  spread  in  many 
countries  previously  exempt  have  awakened  a  general  interest  on  the 
part  of  the  medical  profession  and  stimulated  the  study  of  the  sani- 
tary measures  best  adapled  to  its  suppression  and  control. 


618  MORROW — LEPROSY. 

Leprosy  in  Various  Countries. 

Among  the  Jews. 

Leprosy  lias  the  distinction  of  being  more  frequently  spoken  of  in 
the  Sacred  Scriptures  than  any  other  disease.  From  the  freciuencj- 
with  whicli  it  is  mentioned  and  the  prominence  given  to  the  measures 
instituted  by  the  great  Hebrew  lawgiver  for  its  repression,  it  is  evident 
that  leprosy  overshadowed  in  importance  all  other  diseases  of  that 
period.  From  the  Mosaic  writings,  the  Talmud,  and  other  historical 
records  we  have  evidence  that  leprosy  was  present  during  the  entire 
period  of  the  early  history  of  the  Jews,  and  that  the  sanitary  regula- 
tions prescribed  in  Leviticus  were  framed  chiefly  for  the  control  and 
suppression  of  this  formidable  disease. 

It  is  generally  accepted  that  the  Israelites  contracted  leprosy  dur- 
ing their  sojourn  in  Egypt,  where  it  had  existed  from  time  immemo- 
rial, and  that  they  carried  the  disease  with  them  during  their  exodus 
from  Egypt,  and  that  it  has  existed  among  them  from  that  time  to 
the  present  day.  At  the  time  of  Christ  leprosy  must  have  been  com- 
mon in  Judea  and  Palestine,  from  the  frequency  with  which  lepers 
are  mentioned.  All  evidence  jDoints  to  it  being  a  commonly  recog- 
nized, if  not  a  prevalent,  disease. 

The  Mosaic  account  of  leprosy  forms  no  exception  to  the  charac-" 
terization  previously  made  of  the  description  of  the  disease  bj^  other 
ancient  writers,  viz.,  that  it  is  exceedingly  vague  and  indistinct  and 
that  it  was  confounded  with  many  skin  diseases  of  a  non-contagious 
character.  It  must  be  remembered,  however,  that  the  medical  knowl- 
edge existing  among  the  Jews  at  that  period  was  not  in  advance  of 
that  of  other  nations  of  the  same  grade  of  civilization.  We  should  no 
more  expect  that  the  Mosaic  description  of  leprosy  should  conform  to 
the  clinical  description  of  the  modern  dermatological  writer  than  that 
the  geological  and  astronomical  teachings  of  the  Bible  would  be  ac- 
cei)ted  as  correct  by  our  modern  scientists. 

This  confusion  of  dissimilar  diseases  under  the  same  name  and 
the  inability  to  distinguish  between  leprosy  and  affections  of  tlie  skin 
are  so  evident  that  they  have  led  to  a  serious  doubt  on  the  part  of 
many  authorities  as  to  whether  the  leprosy  of  the  Bible  can  be  identi- 
fied as  the  same  disease  that  we  now  recognize  under  that  name.  It 
is  certain  that  the  clinical  features  and  course  and  especially  the  rapid 
evolution  of  the  diseases  which  were  classed  as  leprosy  in  the  Hebraic 
records  are  entirely  different  from  the  evolutionary  mode  of  leprosy 
as  we  recognize  it  at  the  present  time. 


LEPROSY  IN  VAEIOUS   COUNTRIES.  619 

Thus,  for  example,  the  Levitical  code  provided  that  successive 
examinations  of  the  suspected  patient  should  be  made  at  intervals  of 
seven  days,  thus  enabling  the  priest  to  note  the  progress  of  the  dis- 
ease. Leprosy  is  so  exceedingly  slow  in  its  evolution  that  a  fortnight 
would  show  absolutely  no  change  in  the  character  of  the  skin  lesions. 
The  thirteenth  chapter  of  Leviticus,  in  which  is  given  a  description 
of  the  disease  and  the  signs  by  which  the  priests  recognized  leprosy 
and  differentiated  it  from  other  diseases  which  were  not  leprous  and 
not  contagious,  has  been  analyzed  at  great  length  and  in  detail  by 
many  writers  on  the  history  of  leprosy.  Much  ingenuity  has  been 
displayed  in  translating  or  interpreting  the  terms  used  by  Moses  to 
conform  to  our  modern  conception  of  the  clinical  features  and  be- 
havior of  leprosy. 

Kaposi  asserts  that  the  leprosj^  of  the  Bible  is  not  -leprosy  at  all, 
but  merely  pigment  changes  which  we  recognize  to-day  as  vitiligo. 

Dr.  J.  F.  Schamberg  has  recently  made  a  critical  study  of  the 
nature  of  the  leprosy  of  the  Bible  with  a  view  of  determining  whether 
it  is  identical  with  modern  leprosy.  He  concludes,  first,  that  the 
Biblical  tsaraath  comprises  a  number  of  diseases,  chief  among  which 
were  vitiligo  and  psoriasis ;  second,  that  there  is  no  evidence  in  the 
Biblical  description  to  warrant  the  belief  that  leprosy  existed  among 
the  Jews  at  that  period;  and  third,  that  the  segregation  of  lepers 
had  its  origin  in  the  Biblical  example  of  separating  those  afflicted 
with  tsaraath. 

It  is  generally  conceded  that  both  vitiligo  and  jjsoriasis  were 
classed  in  the  Levitical  code  with  leprosy.  For  example,  in  verses 
12  and  13 :  "  And  if  leprosy  shall  break  out  abroad  in  the  skin,  and 
the  leprosy  covereth  all  the  skin  of  him  that  hath  the  plague  from  his 
head  even  to  his  feet,  then  the  priest  shall  consider,  and  behold  if  the 
leprosy  hath  covered  all  his  flesh  he  shall  pronounce  him  clean  that 
hath  the  plague.  It  hath  all  turned  white  and  he  is  clean."  This 
description  evidently  does  not  refer  to  leprosy,  but  probably  to  vitil- 
igo. In  the  opinion  of  Erasmus  Wilson  it  refers  to  psoriasis.  Again 
in  verses  7  and  8,  "  but  if  the  scab  increase  in  size  and  spread  after  he 
hath  been  seen  of  the  priest  for  his  cleansing,  he  shall  be  seen  of  the 
priest  again,  and  if  the  priest  see  that  the  scab  still  spreadeth  in  the 
skin,  then  the  priest  shall  pronounce  him  unclean.  It  is  leprosy." 
The  disease  referred  to  in  the  above  version,  according  to  Dr.  Scham- 
berg, is  psoriasis,  while  other  commentators  regard  it  as  a  form  of 
leprosy. 

It  is  not  possible  for  lack  of  space  to  enter  into  an  analysis  of  the 
arguments  used  pro  and  con  as  to  the  identity  of  the  leprosy  of  the 
Bible  with  modern  leprosy.     While  it  is  certain  that  nothing  corre- 


620  MORROW — LEPROSY. 

spouding  to  the  objective  features  of  tubercular  leprosy  can  be  found 
in  the  Mosaic  descriptions,  there  is  a  general  consensus  of  opinion 
among  authorities  that  the  leprosy  of  the  Bible  is  nerve  leprosy,  such 
as  is  met  with  in  India  and  in  Palestine  at  the  present  day. 

Many  commentators  believe  that  the  affection  of  Job  was  tubercu- 
lar leprosy.  Certainly  the  description  of  the  disease  with  which  Job 
was  afflicted  presented  striking  resemblances  to  this  form  of  the  dis- 
ease. The  fact  that  Job,  Naaman,  and  others  mentioned  as  being 
stricken  with  leprosy  were  restored  to  health  when  suffering  from  a 
disease  recognized  as  incurable  does  not  necessarily  militate  against 
this  view.  In  the  Old-Testament  Scriptures  both  good  and  evil  Avere 
attributed  to  divine  agency,  and  it  is  not  surprising  that  leprosy  was 
regarded  as  a  manifestation  of  divine  life  and  punishment  for  sin,  and 
the  cure  in  any  case  was  regarded  as  miraculous  and  the  work  of 
divine  intervention. 

Egypt. 

Egypt  has  been  termed  the  cradle  of  leprosy.  "  There  is  a  dis- 
ease called  elephantiasis,  which  has  its  rise  on  the  Eiver  Nile"  (Lu- 
cretius). Pliny  the  Elder,  Galen,  and  other  ancient  writers  refer  to 
Egypt  as  the  home  of  the  disease.  There  is  abundant  evidence  that 
it  has  existed  in  Egypt  from  a  period  of  remote  antiquity.  Archaeol- 
ogists have  discovered  in  papyri  found  in  the  tombs  of  the  Pharaohs 
descriptions  which  relate  to  leprosy.  In  the  Medical  Papyrus  of 
Berlin  there  are  frequent  references  to  a  dangerous  and  severe  disease, 
"uchetu,"  which,  according  to  Professor  Macalister,  of  Cambridge, 
there  is  sufficient  evidence  to  identify  as  leprosy.  "If  so,  it  seems  to 
have  been  very  common,  for  both  in  this  work  and  in  the  Papyrus 
Ebers  there  are  manj'  prescriptions  for  it.  The  Papyrus  Ebers  was 
transcribed  in  the  fifteenth  century  before  Christ,  so  that  if  uchetu 
be  the  same  as  the  Coptic  ouseht  which  is  used  in  the  Pentateuch  for 
leprosy  it  would  be  evident  that  the  disease  prevailed  then." 

"  The  Berlin  Papyrus  found  in  the  necropolis  at  Memphis  contains 
many  prescriptions  for  the  cure  of  malignant  leprosy,  as  well  as  many 
other  kinds  of  illness  and  fractures.  It  was  discovered  in  a  writing- 
case  of  very  ancient  origin  underneath  the  feet  of  the  divine  Anubis 
in  the  town  of  Sokhem  (the  Letopolis  of  the  Greeks  and  Eoraans)  at 
the  time  when  the  deceased  Sapti  was  king  (4166  B.C.)"  (Thin). 

Experts  in  the  Assyrian  and  Babylonian  hieroglyphics  state  that 
stones  discovered  in  the  ruins  of  Babylon  present  inscriptions  which 
relate'  to  leprosy,  and  they  carry  imprecations  against  any  one  who 
will  dare  to  touch  or  displace  them. 


leprosy  in  various  countries.  621 

India. 

It  is  stated  that  leprosy  has  existed  in  India  for  at  least  three 
thousand  years.  In  the  earlier  times  it  was  called  "kushta."  Many 
centuries  before  Christ,  the  exact  date  unknown,  Atreya  refers  to 
seven  varieties  of  kushta.  There  can  be  no  doubt  that  leprosy  was 
common  in  India  six  hundred  years  before  Christ  (Susruta).  Some 
writers  believe  that  it  had  its  source  in  China  and  spread  eastward ; 
others  believe  that  it  came  from  India,  and  others  again  from  Egypt. 

China. 

There  are  references  in  the  earlier  Chinese  M'^ritings  to  a  disease 
which  is  thought  to  be  leprosy,  and  there  would  seem  to  be  no  doubt 
that  the  disease  existed  in  China  long  before  the  Christian  era.  Ac- 
cording to  Thin,  a  writer  of  the  earlier  Han  dynasty,  two  thousand 
years  ago,  describes  a  disease  which  may  refer  either  to  leprosy  or 
syphilis.  Dr.  Monroe  suggests  that  leprosy  may  have  been  introduced 
into  China  from  India,  although  he  infers  from  the  absence  of  distinct 
evidence  to  the  contrary  in  early  Chinese  writings  that  the  disease 
was  less  common  in  ancient  times  in  China  than  it  is  now. 

Greece. 

It  is  not  known  at  what  precise  date  leprosy  was  introduced  from 
Asia  into  Greece.  Hippocrates  writes  of  leprosy,  but  it  is  evident 
that  he  was  acquainted  with  the  disease  only  from  descriptions.  He 
states  that  the  leukai,  "white  diseases,"  spring  from  the  most  deadly 
diseases,  such  as  what  is  called  the  Phoenician  disease,  and  this 
Phoenician  disease  has  been  understood  by  those  who  accept  that 
reading  to  mean  leprosy  (Thin). 

Aristotle,  who  wrote  three  hundred  and  forty-five  years  before 
Christ,  refers  to  the  Phoenicia*  disease  as  common  in  Phoenicia  and 
other  Oriental  parts,  and  calls  it  satyria,  in  which  the  countenance 
seems  to  resemble  that  of  an  animal  or  a  satyr.  He  compares  the 
term  satyria  with  elephantiasis,  a  term  used  by  Greek  writers  for  true 
leprosy.  From  his  description  he  must  have  referred  to  tubercular 
leprosy.  Herodotus,  writing  four  hundred  and  forty-six  years  before 
Christ,  was  the  first  to  use  the  word  elephas  for  the  animal,  and  he 
only  refers  to  it  as  existing  in  Ethiopia  among  other  wild  beasts. 

It  is  probable  that  at  that  period  leprosy  found  its  way  to  the 
coast  of  Asia  Minor  near  Greece,  probably  to  the  latter.  It  is  certain 
that  it  was  quite  common  in  Greece  in  the  last  two  centuries  before 
Christ. 


622  MOKROW — LEPROSY. 

Aretseus,  who  wrote  eighty-one  ^ears  after  Christ,  and  also  in 
the  second  ceuturj^  says  that  elephantiasis  is  called  satyriasis  on 
account  of  the  supposed  libidinous  tendencies  of  the  i:)atients,  while 
Galen  states  that  the  word  has  been  used  on  account  of  the  resem- 
blance of  the  leper's  face  to  that  of  a  satyr. 

It  was  called  leoutiasis  bj''  Archigenes,  who  wrote  in  97,  and  leon- 
tia  by  AretaBUS,  on  account  of  the  supposed  resemblance  to  the  leonine 
face  produced  by  the  thickened  folds  of  skin  on  the  forehead. 

Aretajus,  in  the  first  century  of  our  era,  gave  a  clear  and  cor- 
rect description  of  the  clinical  features  of  leprosy.  Thin,  from  whose 
work  the  following  translation  of  Arets^eus  is  taken,  says  in  compar- 
ing the  description  of  Aret?eus  with  the  vague  and  imperfect  allusions 
in  Hebrew,  Sanskrit,  and  Egyptian  literature :  "  We  appreciate  the 
enormous  intellectual  advances  which  have  been  made  by  the  genius 
of  the  Greek  race. " 

"Formerly  this  affection  was  called  leontiasis,  on  account  of  the 
resemblance  between  the  disease  and  the  lion,  produced  by  the 
appearance  of  the  raised  part  of  the  forehead,  which  I  shall  mention 
later  on;  satyriasis,  on  account  of  the  redness  of  the  cheeks,  as  well 
as  of  the  insurmountable  and  shameless  inclination;  Herculean, 
because  there  is  no  disease  which  is  graver  and  more  violent.  Its 
power  is  indeed  formidable,  for  of  all  diseases  it  is  the  one  which 
possesses  the  most  energy, 

"  Like  the  elephant,  it  is  terrible  and  hideous  from  manj'  ijoints 
of  view.  It  is  irresistible,  inasmuch  as  from  the  beginning  it  carries 
in  itself  the  cause  of  death  ;  that  is  to  say,  a  chilling  of  the  congenital 
heat  or  a  glacial  cold  like  that  of  a  rigorous  winter,  in  which  water  is 
transformed  into  snow  or  ice— altogether  a  horrible  cause  of  sickness 
and  death  indeed. 

"  At  the  beginning  the  disease  is  not  characterized  by  anv  distinc- 
tive sign,  the  patient  not  being  affected  by  any  unusual  symptom. 
It  does  not  show  itself  at  first  on  the  surface  of  the  body,  so  that  it 
cannot  be  observed  and  remedied  at  the  outset,  but  is  concealed  in 
the  bowels  as  in  a  subterranean  abyss,  and  after  having  burned  the 
internal  parts  it  kindles  up  a  fresh  inflammation  on  the  external  sur- 
face, and  most  frequently  the  horrible  fire  visible  manifests  itself  first 
in  the  face,  but  sometimes,  on  the  contrary,  it  begins  on  the  elbow, 
knee,  and  the  joints,  as  well  as  on  the  feet  and  hands.  Persons  thus 
attacked  have  no  hope  of  cure,  because  the  physician,  bj''  carelessness 
or  ignorance  of  the  true  nature  of  the  disease,  does  not  apply  his  art 
when  the  first  symptoms  appear. 

"  The  patients  are  dull,  taciturn,  drowsy  for  a  time,  and  suffer 
from  constipation,  but  all  of  these  symptoms  are  not  of  themselves 


LEPROSY   IN   VAEIOUS   COUNTRIES.  623 

extraordinary,  for  tliey  occur  in  people  otherwise  healthy.  When 
the  disease  has  made  progress,  the  breath  becomes  fetid  on  account 
of  the  internal  decomposition  of  the  vital  forces.  The  urine  becomes 
thick,  white,  frothy,  like  that  of  a  beast  of  burden.  The  patients 
digest  without  difficulty  raw  food,  and  do  not  appear  to  observe 
whether  the  digestive  functions  are  affected.  The  loss  of  digestion  in 
them  is  not  noticed,  for  though  in  general  they  receive  no  benefit 
from  the  food,  digestion  appears  to  be  easy,  as  if  the  disease  devoured 
food  for  its  own  sustenance. 

"  Tumors  arise  one  by  the  side  of  another,  not  continuous  but 
thick  and  unequal.  Amongst  the  tumors  there  are  fissures  as  in  the 
skin  of  the  elephant.  The  veins  are  increased  in  volume,  not  by 
abundance  of  blood,  but  by  the  thickness  of  the  integuments.  The 
hairs  for  the  most  part  die.  They  become  scanty  on  the  thighs, 
calves  of  the  legs,  groin,  and  on  the  chin.  The  hair  of  the  head 
becomes  thin,  gra}^  and  a  rather  pronounced  baldness  appears  pre- 
maturelj^  Soon  the  crown  and  chin  are  completely  denuded  of  hair, 
and  if  any  remains,  however  little,  it  serves  only  to  disfigure  the 
patient.  The  skin  of  the  head  is  deeply  wrinkled.  More  prominent 
tumors  appear  on  the  face.  They  are  sometimes  white  at  the  sum- 
mit, but  greenish  at  the  base.  The  pulse  is  feeble,  heavy,  slow  as  if 
moved  with  difficulty. 

"  The  vessels  in  the  temples  and  under  the  tongue  are  swollen. 
The  stomach  is  filled  with  bile.  The  tongue  becomes  unequal  on 
account  of  granular  nodosities,  and  it  is  not  surprising  to  see  the 
whole  body  covered  with  similar  nodules.  But  if  the  disease  develops 
rapidly  in  internal  parts  and  shows  itself  on  the  extremities,  lichen- 
ous  eruptions  develop  which  sometimes  surround  the  chin  in  a  circle. 
The  cheeks  become  red  and  swell  a  little.  The  eyes  are  dark  and 
copper-colored;  the  eyebrows  prominent,  thick,  bare,  and  overhang- 
ing. The  space  between  them  is  contracted.  The  color  is  leaden 
gray  and  blackish.  The  lower  part  of  the  frontal  skin  is  drawn  down- 
wards and  conceals  the  eyes,  as  in  mad  persons  and  lions.  This  is 
why  the  affection  is  also  called  leonine.  There  are  dark  tumors  on 
the  nose,  which  is  pointed  and  prominent.  The  lips  are  thick,  the 
lower  one  being  blue-back  in  color.  The  teeth  are  destitute  of  white- 
ness and  are  blackish.  The  ears  are  red,  but  inclined  to  become 
black,  the  apertures  are  apparently  larger  than  usual,  and  at  their 
lower  parts  there  are  ulcers  from  which  flows  a  very  pruriginous 
matter.  There  are  also  upon  the  whole  body  wrinkles,  deep  incisions 
as  well  as  furrows.  This  is  why  the  disease  bears  also  the  name  of 
elephantiasis. 

"  The  soles  of  the  feet  as  far  as  the  middle  of  the  toes  are  cracked. 


624  MORROW— LEPROSY. 

If  the  disease  increases,  the  nodosities  of  the  cheeks,  chin,  fingers, 
and  nose  become  ulcerated.  These  ulcers  are  fetid.  They  are  incur- 
able and  appear  in  continous  succession.  Sometimes  the  limbs  per- 
ish before  the  individual,  and  at  last  there  is  seen  to  fall  the  nose,  the 
fingers  and  toes,  feet,  hands,  and  genital  parts,  for  it  is  only  after  the 
patient  is  dismembered  that  the  disease  causes  death  as  a  deliverance 
from  a  horrible  life  and  fearful  sufferings.  But  this  affection  has  the 
same  tenacity  of  life  as  the  elephant.  The  taste  is  lost.  Neither 
eating  nor  drinking  gives  pleasure  to  the  patient. 

"  In  consequence  of  their  sufferings  they  have  an  aversion  to  every- 
thing. They  abstain  from  food  and  have  a  strong  inclination  to  sex- 
ual ajjpetite.  Languor  is  manifested.  Weakness  is  i)articularly 
revealed  in  every  limb,  and  even  the  small  members  are  a  burden  to 
the  sufferer.  The  body  finds  everything  repugnant.  It  does  not  feel 
satisfaction  either  in  the  bath  or  in  abstinence  from  it,  eating  or  fast- 
ing, exercise  or  repose,  for  the  malady  is  in  enmity  with  everything. 
Sleep  is  insignificant.  Watching  is  worse  on  account  of  hallucina- 
tions. The  respiration  is  greatly  disturbed.  The  i)atients  often  feel, 
as  it  were,  strangled  with  a  cord.  Some  thus  finish  a  remnant  of 
existence  in  sleeping,  a  sleep  from  which  there  is  no  rising  until  death 
occurs.  Such  being  their  condition,  who  can  avoid  flying  from  them? 
Who  will  not  turn  away  from  them,  were  it  even  his  father,  or  son, 
or  own  brother?  There  is  also  the  fear  that  the  disease  may  be  com- 
municated. Many  for  this  reason  remove  their  dearest  ones  to  soli- 
tude or  to  the  mountains.  Some  preserve  them  from  hunger  for  a 
time,  others  not  at  all,  desiring  their  death." 

Arabia. 

There  is  no  authentic  historical  evidence  of  the  existence  of  lep- 
rosy in  Arabia  before  the  time  of  Mohammed,  although  from  its 
known  prevalence  in  Egypt  and  Syria  from  the  earliest  times  the  close 
communication  between  these  countries  and  Arabia  would  render  it 
jn-obable  that  the  disease  was  carried  to  Arabia  at  an  early  period. 
Kaposi  gives  a  long  list  of  Moorish  and  Arabian  writers  who  have 
l^roduced  treatises  on  leprosy,  partly  borrowing  from  the  Greeks  and 
partly  basing  their  descriptions  upon  their  own  observations  of 
the  disease. 

Italy  and  Continental  Europe. 

According  to  Aretaeus,  it  had  in  his  time  begun  to  spread  into 
Western  Europe.  The  Romans  ac(iuired  leprosy  after  the  Greeks. 
Celsus,  Galen,  and  Pliny  thought  that  it  was  imported  into  Italy  by 


LEPEOSY  IN  VAEIOUS  COUNTRIES.  625 

the  troops  of  Pompey  and  tliat  leprosy  had  gained  Italy  about  one 
century  before  Christ.  Henceforth  its  spread  was  rapid  over  Europe. 
We  can  trace  it  into  France,  Spain,  Great  Britain,  Germany,  Kussia, 
and  Scandinavia.  We  find  it  rising  and  declining  at  different  periods 
and  in  different  parts  of  the  world,  moving  gradually  from  east  to 
west  and  from  south  to  north.  While  it  is  found  prevalent  in  Egypt 
and  India  in  the  early  period  of  the  world's  history,  in  the  beginning 
of  the  Christian  era  it  spread  through  Greece  and  Southern  Europe 
during  the  period  ranging  from  the  sixth  to  the  seventh  centuries, 
reaching  its  culminating  point  during  the  crusade  in  the  eleventh 
and  twelfth  centuries,  and  began  to  decline  from  the  fifteenth  to  the 
seventeenth  centuries. 

The  traditional  idea  that  leprosy  was  introduced  into  Europe  by 
the  crusaders  is  without  foundation.  It  prevailed  extensively  in  Wes- 
tern Europe  long  before  the  crusades  were  instituted,  although  there 
is  no  doubt  that  the  movements  of  the  crusaders  to  and  fro  afforded 
effective  means  for  the  further  spread  of  the  disease.  Certain  writers 
have  attributed  its  introduction  into  Western  and  Eastern  Europe 
from  Asia  Minor  to  other  agencies.  Simpson  suggests  it  may  have 
been  brought  by  Roman  armies  or  by  numerous  pilgrims  who  were 
accustomed  to  flock  to  Jerusalem  from  various  parts  of  Europe.  Even 
before  the  foreign  armies  left  Britain  in  418  numerous  pilgrimages 
had  been  made  to  Jerusalem.  There  were  abundant  opportunities 
for  contracting  the  disease  in  Jerusalem,  where  it  had  existed  from 
time  immemorial. 

Great  Britain. 

The  early  history  of  leprosy  in  Great  Britain  has  been  studied 
with  great  care  by  Sir  James  Y.  Simpson.  He  regarded  it  as  prob- 
able that  leprosy  was  introduced  into  Great  Britain  by  processions 
of  pilgrims  to  the  Holy  Land  going  and  returning  through  Italy ;  the 
opportunity  for  contagion  being  afforded  in  both  these  countries. 
The  pilgrimages  to  the  Holy  Land  were  of  frequent  occurrence,  and 
the  conditions  of  travel  at  that  time  necessitated  the  close  con- 
tact and  intimate  relations  which  favored  the  communication  of  dis- 
ease. 

Newman  also  has  made  an  admirable  study  of  the  "History, 
Decline,  and  Final  Extinction  of  Leprosy  as  an  Endemic  Disease 
in  the  British  Islands."  His  researches  prove  that  leper  hospitals 
existed  in  Ireland  and  that  leprosy  was  prevalent  in  England  long 
before  the  first  Englishmen  engaged  in  the  crusades.  The  disease 
spread  more  or  less  rapidly  through  England,  Wales,  and  Ireland, 
although  it  always  prevailed  more  extensively  in  certain  localities 
YoL/xyill.— 40 


620  MOREOW— LEPROSY. 

than  in  others.  It  was  very  prevalent  in  the  twelfth,  thirteenth,  and 
fourteenth  centuries,  as  shown  hy  the  number  of  leper  houses  that 
existed  and  by  the  ecclesiastical  and  legal  regulations  that  were  pro- 
mulgated in  respect  to  them.  The  disease  was  also  common  in  the 
fifteenth  and  sixteenth  centuries,  but  had  then  begun  to  decline. 
During  the  reign  of  Edward  VI.  (1547-1563)  it  was  reported  by  a 
commission  that  most  of  the  lazar  houses  in  England  were  empty. 

It  is  not  kno^n  at  what  precise  jieriod  leprosy  was  first  introduced 
into  Scotland,  but  the  general  impression  is  that  it  was  a  centur^^  or 
two  after  its  introduction  into  England.  The  earliest  lazar  house  in 
Scotland  dated  back  to  1150.  Numerous  lazar  houses  were  estab- 
lished in  various  parts  of  the  kingdom  during  the  next  two  or  three 
centuries.  The  decline  of  leprosy  in  Scotland  was  noticed  in  1652  by 
an  act  for  the  diminishing  of  the  houses  at  Edinburgh,  but  the  dis- 
ease still  prevailed  in  the  islands  to  the  north  of  Scotland  and  in  the 
Shetland  Islands.  In  1742  a  public  thanksgiving  was  ordered  for  the 
permanent  disappearance  of  leprosy  from  the  Shetland  Islands.  The 
last  leper  of  the  Shetland  Islands,  it  is  stated,  died  in  the  Edinburgh 
Infirmary  in  1798. 

The  disease  began  to  disappear  in  France  and  Italy  at  the  end  of 
the  sixteenth  century,  although  leprosy  centres  were  found  on  the 
south  Mediterranean  coast  in  the  seventeenth  century. 

In  Norway  there  is  a  record  of  the  establishment  of  a  leprosy  hos- 
pital at  Bergen  in  1276,  and  the  number  of  lepers  was  found  to  be 
increasing  in  1745.  A  leper  hospital  was  established  in  Austria  in 
1301  and  in  Sweden  in  1248.  Evidence  is  abundant  that  leprosy  was 
present  in  Denmark. 

Leper  hospitals  were  also  established  in  Iceland  in  the  fifteenth 
and  sixteenth  centuries. 

North  and  South  Ajierica. 

In  America  the  history  of  the  introduction  of  leprosy  and  its  spread 
in  the  British  provinces  of  North  America,  the  United  States,  and 
South  America  cannot  be  definitely  traced.  There  are  ho  authentic 
records  of  its  existence  in  New  Brunswick  until  1815.  It  was  intro- 
duced into  Louisiana  by  the  Acadian  refugees  who  were  deported 
from  Nova  Scotia. 

In  South  America  leprosy  was  introduced  by  the  French,  Spanish, 
and  Portuguese  settlers,  with  an  added  increment  of  infected  ma- 
terial from  Africa,  the  East  Indies,  and  elsewhere. 

Kubler,  in  his  remarks  upon  the  geography  of  leprosy,  suggests 
that  there  is  some  connection  between  leprosy  in  America  and  Africa, 


LEPEOSY   IN   VARIOUS   COUNTRIES.  627 

as  the  countries  most  occupied  are  on  the  side  looking  towards  Africa. 
A  question  of  some  importance  in  this  connection  is  that  of  pre- 
Cohimbian  leprosy.  Dr.  Ashmead  has  made  a  very  careful  and  elab- 
orate study  of  pre-Columbian  leprosy,  in  which  he  has  examined  col- 
lections of  the  pottery  found  by  the  sides  of  mummies,  the  hands 
and  feet  of  mummies  from  Peru,  from  Chihuahua,  North  American 
Indian  remains,  and  from  Mexico,  and  various  other  presumably  pre- 
historic remains  from  numerous  other  localities.  In  none  of  these 
bones  was  there  any  evidence  of  leprosy.  Nor  were  there  any  de- 
formities depicted  on  the  American  pottery  which  could  be  identified 
as  characteristic  of  leprosy. 

Within  recent  times  leprosy  has  been  widely  disseminated  in 
the  far  East  and  in  the  islands  of  the  Pacific  chiefly,  it  is  generally 
held,  by  the  Chinese.  Cantlie  declares  that  "  the  Chinaman  taints 
the  world  with  leprosy,"  and  he  brings  forward  historical  evidence 
to  prove  that  the  spread  of  leprosy  in  the  Malay  peninsula,  the 
Dutch,  Spanish,  and  Portuguese  East  Indies,  and  in  Oceanica,  as 
well  as  the  islands  of  Fiji,  New  Caledonia,  Hawaii,  and  the  western 
coast  of  America,  may  be  traced  to  Chinese  coolie  immigrants.  "  The 
Chinamen  are  not  only  the  probable  introducers,  but  the  chief  vic- 
tims. With  the  exception  of  Hawaii  and  New  Caledonia,  all  over 
Indo-China,  Malaya,  the  Indian  archipelago,  and  the  Pacific  it  is  the 
Chinaman  who  is  the  dominant  leper." 

Whether  these  Bohemians  of  the  Orient  have  carried  leprosy  with 
them  in  their  world-wide  migrations,  or  whether  they  simply  serve  as 
scapegoats,  the  opinion  generally  prevails  that  they  have  been  the 
chief  contaminators  of  the  world  with  leprosy  in  modern  times. 

The  following  chronological  table,  which  gives  the  chief  dates  in 
the  history  of  leprosy  which  has  been  compiled  from  the  most  authen- 
tic sources  accessible,  is  taken  from  the  prize  essay,  "  The  History 
of  the  Decline  and  Final  Extinction  of  Leprosy  as  an  Epidemic  Dis- 
ease in  the  British  Islands,"  by  George  Newman,  1895.  The  writer 
has  supplemented  it  with  a  few  dates,  while  omitting  many  details 
relating  to  the  leper  houses  in  Great  Britain  which  are  of  less  general 
interest : 

Chronological  Table  of  Leprosy. 

B.C. 

3500.  Leprosy  in  Egypt  (Husapti?).  ' 

1320.  The  exodus. 

1000-900.   Celts  in  England.- 

600-400.   Leprosy  common  in  Hindoostan  (Susruta)  and  China. 

460.  Hippocrates  described  leprosy. 

260.  Manetho  testified  to  presence  of  leprosy  among  the  Jews  (90,000). 

200.  Leprosy  common  in  Greece,  called  elephantiasis  (Kaposi). 


628  MOREOW — LEPROSY. 

100.  Leprosy  known  in  Italy. 
95.  There  is  a  disease  called  elephas  which  has  its  rise  on  the  river  Nile  in  the 

middle  of  Egypt  (Lucretius). 
60.  Leprosy  first  in  Spain. 
53.  Celsus  wrote  on  leprosy. 

A.D. 

81.  Areta3us  wrote  on  leprosy  ;  also  in  second  century  (?). 
97.  Archigenes  wrote  on  leprosy  also. 
Second  century.  Leprosy  became  prevalent  in  Europe  between  the  second  and  the 

sixth  centuries. 
Fourth  century.  Theodoret  mentions  lazarettos  for  lepers. 
360.  Oribazius  wrote  on  leprosy. 
366.  Order  of  St.  Lazarus  founded  in  Palestine. 
Fifth  century.  Actius  wrote  on  lepros3^  describing  it  as  widespread. 
433.  First  notice  of  leprosy  in  Ireland  (Colgan's  "Acta  Sanctorum"). 
500.  Charaka  wrote  on  leprosy. 

Sixth  century.  Gregory  of  Tours  speaks  of  lazarettos. 
549.  Council  of  Orleans  leprosy  decree. 

.550.  Pestilence  of  leprosy  in  Ireland  ("Chronicon  Scotorum  "). 
588.   Council  of  Lyons  leprosy  decree. 
Seventh  century.  Hospital  St.  John  founded  for  lepers  (Lake  Constance).     Leper 

houses  existed  at  Verdun,  Metz,  and  Mastricht  (Virchow). 
603.  St.  Kentigern,  of  Glasgow,  died:  " mundabat  leprosos. " 
606.  Increase  of  leprosy  during  a  Roman  invasion  in  the  time  of  Heraclius  (Lani- 

gan,  "Eccles.  Hist."). 
661-664.  Leprosy  in  Brittany. 

Rothar,  King  of  Lombards,  made  laws  to  prevent  the  marriage  of  lepers. 
Pestilence  depopulated  Britain  and  Ireland. 
Eighth  century.  St.  Boniface  "mundabat  leprosos.  "     Hospital  St.  Lazarus  founded 
at  St.  Gallen,  Lake  Constance,  720.     St.  Othmar  founded  leper  houses 
in  Germany  (died,  758).     St.  Nicholas  of  Corbie  founded  leper  houses 
in  France.     Isidore  of  Spain  alludes  to  leprosy  in  Spain. 
757.   Pepin  provided  an  act  that  leprosy  should  be  sufficient  cause  for  separation 

or  divorce  (Parliament  at  Compiegne) . 
789.  Charlemagne  re-enacted  similar  laws;  also  enforced  sequestration. 

868.  Council  of  Worms  leprosy  decree. 

869.  Leper   hospitals  existed  in  Ireland.     The  hospital  at  Armagh  burned  by 

Arlaf. 
874.  Iceland  peopled  from  Norway. 
Tenth  century.  Leprosy  prevalent  in  Europe  ;  in  England.    Leper  laws,  Venedotian 
and  Dimetian  codes.     Law  was  passed  in  England  making  leprosy  a 
cause  for  divorce. 
933.  Truela,  son  of  King  Alfonso  of  Spain,  dies  of  leprosy. 

Leper  houses  had  existed  in  Palestine  for  nearly  a  thousand  years. 
950.  Hywel  Dda,  or  Howell  the  Good  (a  Welsh  king  who  died  about  950),  en- 
acted a  code  of  laws  relative  to  leprosy  ("Celtic  General  Repository," 
vol.  iii.,  199). 
958.  Leprosy  mortality  excessive.     Suffering  and  misery  throughout  Europe. 
1007.  Leprosy  prevalent  in  Spain.     In  this  century  first  leper  hospitals  and  pest 

houses  were  built. 
1067.  First  leper  hospital  in  Spain  (Valencia) . 


LEPEOSY  IN   VAEIOUS   COUNTRIES.  629 

1075.  Hugh  D'Orivalle,  Bishop  of  London,  had  leprosy. 

1084.  Several  leper  hospitals  founded  in  England  previous  to  first  crusade. 

Leper  hospital  founded  at  Canterbury  by  Lanfranc  (Archbishop  of  Canter- 
bury), who  died  1089. 

1095.  First  Crusade  begun  by  Peter  the  Hermit. 

1098.  Return  of  the  first  Crusaders.  Low  condition  of  English  agriculture,  misery, 
famine,  and  pestilence. 

Twelfth  century.  It  was  a  custom  before  this  century  to  burn  and  otlierwise  perse- 
cute lepers  in  Europe.  Henry  H.  in  an  edict  sanctions  it  in  England. 
The  writ  "  De  Leproso  Amovendo  "  in  force  at  this  period.  The  earliest 
mention  of  leper  houses  in  Scotland.  Knights  of  St.  Lazarus  acquired 
a  footing  in  England  (Stephen).  Leprosy  prevalent  in  Denmark 
(Gislasen) .  Third  crusade  under  Richard  I.  Baldwin  I. ,  King  of 
Jerusalem,  became  a  leper  and  ten  years  later  resigned  his  crown  be- 
cause of  disablement  (1184).  Founding  of  numerous  leper  houses 
in  England  and  Scotland  (first  in  Ireland,  1165).  ,Over  fifty  leper 
houses. 

1179.   Council  of  Lateran,  famous  leprosy  decree. 

1181.  Pope  Lucius  III.  's  leprous  decree. 

1190.  Pope  Clement  III.  's  leprous  decree. 

1192.  Famine  in  England.     Approximate  time  of  appearance  of  leprosy  in  Iceland. 

1200.  Leprosy  decree  of  Provincial  Synod  at  Westminster ;  Hubert,  Archbishop  of 
Canterbury.     Henry  III.  visited  lepers  every  Holy  Thursday. 

Thirteenth  century.  Leprosy  reached  its  zenith  during  this  century  (Liveing)  (?). 
Period  of  returning  Crusaders.  Louis  Vni.  's  code  of  French  leper 
laws.  Two  thousand  leper  hospitals  in  France.  Equal  number  in 
middle  of  fifteenth  century  (Heren). 

1242.  Leprosy  canons  of  Scotch  Church,  separating  lepers  from  society. 

1248.  Ferdinand  III.  founded  leper  hospital  at  SevUle. 

1250.  Leprosy  existed  in  Japan. 

1263.  Norwegians  invaded  England,  and  in  1266  first  mention  of  leper  houses  at 
Bergen,  Norway. 

1269.  Leprosy  segregation  of  the  canons  of  the  Scotch  Church. 

1270.  St.  Louis  of  France  on  the  last  crusade.     Many  of  his  soldiers  became  leprous 

(Joinville). 

1283.  Statutes  of  Society  of  Merchants  ordered  that  lepers  should  not  come  into 
the  burgh. 

1290.  Council  of  Nogaro  exempted  lepers  from  the  jurisdiction  of  secular  justices, 
prohibited  their  entrance  into  markets  or  towns,  and  insisted  on  their 
wearing  some  distinguishing  badge. 

1296.  Leprosy  in  Edinburgh.     Fifty  leper  hospitals  built  in  thirteenth  century. 
Leprosy  prevalent,  but  probably  declining. 
A  leprosy  "visitation"  in  the  west  of  England  (Somerset,  etc.). 

Fourteenth  century.  Commencing  decline  of  leprosy  throughout  Europe  during 
this  century.  Numerous  leper  houses  built  in  England  and  Scotland. 
Lepers  getting  scarce  at  various  places.  Leprosy  visitation  in  west  of 
England.     Regulations  against  lepers  entering  city  of  London. 

1350.  Lepers  getting  scarce  at  St.  xllbans  and  Aylesbury. 

1357.  Black  Death  in  Europe  ;  in  England  1349.  Laws  passed  in  England  protect- 
ing fishers  and  for  the  supply  of  fresh  fish  instead  of  dried.  Laws 
passed  against  water  pollution.     13S9,  cleansing  the  streets. 


630  MORROW — LEPROSY. 

1365.  There  were  now.  four  leper  houses  at  York,  and  they  remained  for  just  one 
hundred  years  (Rol)ertson). 

1375.  Regulations  against  lepers  entering  the  city  of  London;  the  taking  of  the 
oath  hy  John  Gardener. 

1889.  Renewal  of  persecution  of  lepers  in  France  (Charles  VI.). 

1398.  John  of  Gauut's  will,  bequeathing  to  London  lepers.  Henry  IV.  a  leper 
(according  to  Gascoigne) . 

Fifteenth  century.  1407.  Great  plague  in  London.  Numerous  leper  houses  pro- 
vided in  Switzerland  and  Spain. 

1413.  St.  Mary  Magdalene  Hospital  at  Reading  closed  because  no  lepers  forthcoming. 

1414.  Leper  hospitals  in    England    "for.tlie  most    part   decayed,   and  the   goods 

thereof  spent  in  other  use"  (2  Hy.  V.,  c.  i.). 

1427.   Scottish  Parliament  compelled  to  legislate  for  lepers  (1427,  c.  8,  ii.,  16). 

1468.   The  leprosy  certificate  of  the  court  physicians  of  Edward  IV. 

1470.  A  royal  commission,  appointed  by  Edward  IV.,  reported  marked  decrease 
of  leprosy. 

1485.  Lepers  still  in  London,  and  a  number  of  legacies  left  to  them  ("Calendar  of 
Wills,"  vol.  ii. ).     Leprosy  by  no  means  rare  in  Lincolnshire. 

Sixteentli  centm-y.  Leper  hospitals  still  being  founded  in  Netherlands  and  parts  of 
Germany  and  Spain.  Final  extinction  of  leprosy  in  Denmark  (Gis- 
lasen.) 

1536-1540.  Suppression  of  the  monasteries  and  many  of  the  existing  leper  houses  ; 
but  the  larger  ones  were  spared  by  Edwwd  VI.  (c.  3),  "to  prevent  the 
contagion  spreading."  A  royal  commission  (Edward  VI.)  reported 
most  of  the  leper  hospitals  in  England  empty,  1547.  Leprosy  was  fre- 
quent in  Cornwall  in  the  time  of  Elizabeth  (Polwhele) . 

1542.  Leper  hospital  built  on  Canary  Islands. 

1555.   Leprosy  very  prevalent  in  Iceland. 

1574.  Herbaldowne  Hospital  providing  relief  for  more  than  thirty.  Leper  laws 
made  in  Scotland  ;  repealed,  1579. 

1582.  Refoundation  of  Bodmin  Hospital  by  Elizabeth.  "A  great  company  of 
lazar  people."  Glasgow  lepers  allowed  free  access  to  burgh  (Robert- 
son) till  1593. 

1585.  Sherburn  leper  hospital,  diverted  from  its  original  purpose  (because  no  lepers 
were  forthcoming),  became  a  general  hospital. 

1591.  Five  lepers  consigned  to  hospital  in  Edinburgh.  Lepers  still  at  Aberdeen. 
Apparent  outbreak  of  leprosy  in  Scotland. 

1593.  Glasgow  lepers  banished  from  the  burgh  by  Kirk  Session. 

1598.  Heutzner,  travelling  through  England,  remarks  on  the  frequency  of  leprosy. 
Thirty-nine  lepers  in  Bodmin  Hospital  in  James  I.  's  reign,  who  were 
largely  patronized  by  the  king. 

Seventeenth  century.   Four  le]ier  hospitals  built  in  Iceland,  1651. 

1652.   J'or  "many  years  Ireland  hath  been  almost  quite  freed"  from  leprosy  (Boate). 

1656.  Leper  hospital  built  in  Madeira. 

1657.  An  order  made  to  dismantle  the  lazar  house  .at  Greenside,  Edinburgh. 

1661.  Leper  house  at  Aberdeen  razed  to  the  ground.  Leprosy  was  prevalent  in  the 
Faroe  and  Shetland  Islands. 

1676.   Leprosy  very  prevalent  in  the  Faroe  Islands,  Shetland  Islands,  St.  Kilda,  1684. 

Eighteenth  century.  1707.  Smallpox  epidemic  in  Ireland  killed  one-third  of  popu- 
lation, including  many  lepers.  Leprosy  still  in  France  (Upper 
Auvergue,  etc.),  Belle  Isle  still  used  as  leper  refuge. 


METHODS   OF  DEALING  WITH  LEPEOSY  IN  ANCIENT  TIMES.  631 

1730.  Leprosy  prevalent  in  Ireland  (Von  Triol). 

1749.  Public  thanksgiving  in  Shetland  on  account  of  disappearance  of  leprosy  (fevf 

cases  still  appear). 

1753.  Several  lepers  in  St.  Kilda. 

1759.  One  hundred  and  fifty  lepers  in  Norway  (three  hospitals). 

1768.  Two  hundred  and  eiglity  lepers  in  four  Iceland  hospitals  (Petersen) . 

1769.  Captain  Cook  landed  in  ^ew  Zealand.     Leprosy  present  (?). 
1775.  Last  endemic  case  of  leprosy  in  Ireland  at  Waterford. 

1778.  "A  leper  is  now  a  rare  sight"  (White  of  Selborne). 

1787.  Leprosy  endemic  in  Auvergne. 

1798.  A  man,  John  Burns,  a  Shetland  leper,  descended  from  a  leprous  family,  ad- 
mitted into  the  Edinburgh  Infirmary. 

Nineteenth  century.  Leprosy  unknown  as  indigenous  disease  throughout  the 
British  Islands.  Since  1882  twenty  cases  of  leprosy  have  been  brought 
before  London  Dermatological  Societj^  probably  none  were  indigenous. 

1809.  Supposed  case  of  indigenous  leprosy  in  Edinburgh  ;  another  in  the  Shetlands 

(Edmonston) . 

1810.  Leprosy  endowment  in   Cornwall  transferred  to  general  infirmary  because 

there  were  no  lepers  needing  assistance  (Brown's  "  Cases  in  Chancery,  " 
166,  n.). 

1811.  First  leprosy  hospital  at  Calcutta. 
1815.  Leprosy  in  New  Brunswick. 

1836.  Many  lepers  still  in  Norway  and  Iceland.  Some  in  Portugal,  Spain,  Italy, 
Sicily,  Crete,  New  Zealand,  etc.  Very  prevalent  in  India,  China, 
Japan,  and  the  West  Indies. 

1848.  Leprosy  introduced  into  Hawaiian  Islands. 

1850.  Beginning  of  leprous  endemic  in  Parcent,  Spain. 

1863.  Leprosy  still  common  in  Iceland. 

1866.  Beginning  of  leprosy  endemic  in  Louisiana. 

1867.  Royal  College  of  Physicians  Report  declaring  leprosy  non-contagious. 

1868.  Leprosy  introduced  into  New  Caledonia 
1874.  Leprosy  bacillus  discovered  by  Hansen. 
1885.  Norway  contained  1.377  lepers. 

1889.  Six  hundred  lepers  at  the  Cape  of  Good  Hope. 

1890.  Disease  practically  extinct  in  New  Zealand  ;  18,000  lepers  in  Colombia. 
1892.  Lepers  in  Spain,  1,200;  Norway,   1,200;  600  to  700  elsewhere  in  Europe. 

Lepers  in  India,  100,000;  Japan,  150,000  (?). 
1894.   Iceland,  140;  1897,  200. 
1897.  Berlin  Leprosy  Congress. 


Methods  of  Dealing  with  Leprosy  in  Ancient  and 
Modern  Times. 

Isolation  of  Lepers. 

It  is  to  be  understood  that  a  broad  signification  is  given  to  the 
term  "  isolation"  in  this  connection :  it  will  be  used  synonymously 
with  segregation  or  compulsory  gathering  together  of  lepers. 


632  MORROW— LEPROSY. 

Complete  isolation  of  lepers  is  practically  impossible;  even  in 
countries  where  leper  hospitals  and  asylums  have  been  established 
strict  isolation  of  the  inmates  does  not  exist.  They  come  more  or 
less  in  contact  with  physicians,  nurses,  clergymen,  attendants,  and 
purveyors  of  their  food  and  other  supplies,  so  that  no  leper  commu- 
nit}-  can  be  absolutely  shut  off  from  the  world. 

In  all  ages  and  in  almost  all  countries  mankind  has  waged  a 
relentless  warfare  against  the  leper.  Tlie  belief  in  the  contagiousness 
of  leprosy  which  was  universally  held  from  the  earliest  ages  until 
within  recent  times  has  led  to  an  avoidance  of  contact'  W' ith  those  af- 
flicted with  the  disease,  and  in  most  countries  there  has  been  a  general 
tendency  to  ostracize  or  segregate  tliem.  All  the  severe  proscriptive 
measures  formulated  in  the  Levitical  code  and  those  practised  in  the 
Middle  Ages  were  based  upon  the  belief  that  the  leper  is  a  source  of 
danger  to  those  with  whom  he  msiy  come  in  contact.  Even  in 
countries  where  segregation  is  not  prescribed  by  legislative  enact- 
ments or  enforced  by  governmental  authority,  public  sentiment  has 
restricted  association  with  lepers. 

In  India,  China,  and  Japan,  which  are  among  the  oldest  leprosy 
centres  of  the  world,  public  opinion  has  decreed  that  those  affected 
should  withdraw  from  the  society  of  their  fellows  and  dwell  apart. 
To  this  prevalent  sentiment  may  be  traced  the  origin  of  the  leper  vil- 
lages and  leper  homes  which  form  so  distinctive  a  feature  in  many 
Oriental  countries,  especially  in  China. 

There  is  no  doubt  that  the  attitude  of  public  sentiment  towards 
lepers  is  modified  by  race,  religion,  and  civilization.  Among  certain 
races — the  negroes  of  South  Africa,  the  Kanakas  of  New  Caledonia 
and  of  Hawaii — leprosy  inspires  neither  disgust  nor  fear. 

Dr.  Eoss  says  of  leprosy  in  South  Africa :  "  It  is  a  singular  fact 
that  the  people  among  whom  leprosy  is  spreading  have  no  fear  of 
contagion  among  themselves,  nor  do  they  abstain  from  embracing  or 
handling  each  other.  The  disease,  so  repellant  to  Europeans,  seems 
to  have  no  repulsion  to  them.  They  bitterly  resent  being  parted 
from  their  kith  and  kin.' 

In  an  article,  published  in  1889,  embodying  my  observations  of 
leprosy  in  Hawaii,  I  wrote :  "  The  Hawaiian,  be  it  understood,  has 
not  the  wholesome  horror  of  the  disease  entertained  by  his  more 
civilized  brothers.  He  ignores  its  contagiousness,  and  neither  dis- 
gust nor  fear  leads  him  to  shun  his  brother  leper  as  a  bearer  of  deadly 
contagion.  Leprosy  carries  with  it  no  social  ostracism  and  arouses 
no  instinct  of  self-preservation  on  the  part  of  the  patient's  friends. 
It  is  this  total  absence  of  fear,  this  ignorant  contempt  of  its  conta- 
giousness combined  with  the  promiscuous  and  intimate  intercourse 


METHODS  OF  DEALING  WITH  LEPEOSY  IN  ANCIENT  TIMES.  633 

between  the  liealtliy  and  the  diseased  which  accounts  for  the  rapid 
and  unexampled  spread  of  the  disease  in  these  islands." 

Dr.  Le  Grand  bears  much  the  same  testimony  as  to  the  attitude 
of  the  natives  of  New  Caledonia  towards  those  affected  with  the 
disease. 

Among  Mussulmans  leprosy  does  not  spread  with  the  same  rapidity 
because  it  inspires  a  fear  or  terror  which  prompts  every  person  to 
avoid  contact  with  a  leper,  except  he  happens  to  be  a  member  of  his 
own  family. 

In  the  Isle  of  Mytelene,  Zambaco  Pacha  declared  that  in  a  popu- 
lation of  several  thousand  Mussulmans  there  was  not  a  single  case  of 
leprosy,  which  he  attributes  to  their  wholesome  horror  of  contact 
with  the  disease. 

The  natural  affection  existing  among  members  of  the  same  family 
has  proven  to  be  the  most  formidable  obstacle  to  the  segregation  of 
lepers.  This  sentiment  of  affection  protests  against  the  casting  out 
of  a  member  of  a  family  until  the  disease  becomes  so  disfiguring  as 
to  be  r:pulsive,  and  this  in  connection  with  the  opportunities  of  con- 
tagion inseparable  from  family  life,  is  probably  the  explanation  of  why 
leprosy  is  so  essentially  a  family  disease. 

It  has  been  generally  supposed  that  the  Jews  were  the  first  to  seg- 
regate lepers.  It  is  known,  however,  that  the  Persians  had  laws  for 
the  extermination  of  leprosy  before  the  time  of  Herodotus.  This 
author  states  (edition  Feubrini,  chapter  138):  "If  any  citizen  has^ 
lepra  or  leuce,  he  may  not  enter  into  the  city  or  mingle  with  the  Per- 
sians.    Every  stranger  who  is  attacked  is  exiled  from  the  citj'." 

It  is  probable  that  segregation  was  practised  in  other  countries 
where  leprosy  prevailed.  It  has  been  suggested  that  Moses,  in  sepa- 
rating lepers  from  the  healthy  and  compelling  them  to  dwell  apart, 
followed  the  custom  he  had  seen  practised  in  Egypt.  In  any  case, 
the  policy  of  the  segregation  of  lepers  has  been  perpetuated  with 
varying  degrees  of  severity  and  strictness  from  Mosaic  times  to  the 
present. 

During  the  great  epidemic  of  leprosy  in  Europe  in  the  Mid- 
dle Ages  the  practice  of  segreg^ation  was  prosecuted  with  the  greatest 
rigor. 

Eeference  will  be  found  in  the  section  on  geographical  distribution 
of  leprosy  to  the  barbaric  practice  prevalent  in  many  countries  of  the 
putting  to  death  of  lepers  or  banishing  them  in  the  forests  and  deserts 
to  die  of  hunger  and  exposure. 

In  China,  according  to  Cantlie,  it  has  happened  that  when  a  case 
of  leprosy  had  declared  itself  the  parents,  after  having  drugged  the 
patient,  burned  him  alive. 


684  M.ORROW— LEPROSY. 

Segregation  has  been  sanctioned  by  the  experience  of  centuries  as 
the  best  prophyhxctie  measure  against  the  spread  of  lepros}'. 

The  Levitical  code  decreed  that  the  leper  shoukl  be  cast  out  of  the 
city  and  transported  to  a  place  called  Beth  Chofschitch,  which  means 
"houses  of  impurity."  Not  only  the  leper,  but  his  habitation,  was 
declared  to  be  unclean.  Jewish  lepers  under  tlie  penalty  of  eighty 
stripes  were  forbidden  to  approach  the  mountains  of  the  temple,  yet 
were  not  rigidly  condemned  to  isolation,  and  in  towns  without  walls 
were  even  allowed  to  enter  synagogues.  They  were  required  to  make 
themselves  known  at  the  first  glance  bj^  appearing  in  public  with  rent 
garments,  bare  head,  and  covered  beard,  and  if  anj-  one  approached 
inadvertently  the  lepers  were  to  cry,  "  Unclean,  unclean !"  They  were 
interred  in  a  separate  burial  ground  (Thin). 

We  have  little  definite  knowledge  respecting  the  measures  of  deal- 
ing with  lepers  before  the  invasion  of  Europe  by  the  disease.  Refer- 
ence has  already  been  made  to  the  extent  to  which  leprosy  scourged 
the  population  of  Europe  between  the  tenth  and  sixteenth  centuries. 
We  know  that  during  the  period  of  this  great  epidemic  the  church 
and  State  united  their  immense  authority  to  secure  the  isolation  of 
the  lepers. 

According  to  Dr.  G.  Contenau,  who  has  made  a  special  study 
of  the  proi)hylaxis  of  leprosy  in  the  Middle  iVges,  the  leproseries 
in  France  were  composed  ordinarily  of  low  buildings,  without  venti- 
lation, enclosed  by  walls,  with  gardens,  wells,  chapel,  and  chaplain 
in  most  of  them.  They  were  always  designated  by  the  name  of  a 
patron  saint.  In  France  they  were  under  the  protection  of  St. 
Lazar,  of  St.  Marthe,  or  St.  Madeleine.  In  Central  Europe  they 
were  und;^r  the  protection  of  St.  Jaques.  In  the  north  and  east  of 
Europe  St.  George  was  the  patron  saint,  and  in  Poland  St.  Valentine 
and  St.  Leonard. 

"  They  were  ordinarily  situated  near  a  cathedral  without  the  walls 
of  a  city.  Thej-  were  built  at  the  expense  of  the  king  or  of  the  city 
or  often  by  charitable  private  means.  They  were  supported  often 
by  the  crown  almsbag,  which  was  made  up  of  receipts  from  the  rich 
lepers.  The  excess  of  these  receipts  was  divided  among  the  poor. 
Often  the  leproseries  had  revenues  in  silver  or  in  wine,  barley,  etc. 
Although  in  the  hospitals  in  the  Middle  Ages  there  were  four  or  five 
patients  in  the  same  bed,  and  oftentimes  as  many  upon  the  roof,  the 
projiortion  of  the  lepers  was  always  restricted  in  these  leproseries 
on  account  of  their  immense  number.  When  an  individual  was  recog- 
nized as  lej^rous,  his  admission  was  gratuitous  (by  the  grace  of  God). 
If  he  was  rich,  he  brought  his  house  utensils  and  a  sum  varying  from 
ten  to  fifteen  pounds  sterling.     The  leprosery  was  ordinarily  under 


METHODS   OF   DEALING   WITH   LEPEOSY   IX   ANCIENT   TIMES.  635 

the  charge  of  a  master  or  superior,  assisted  by  leprous  brothers  and 
sisters.  Sometimes  the  chaplain  was  the  chief,  or  instead  a  leper  was 
elected  provost  by  the  lepers.  The  ceremony  of  the  entrances  in  a  lep- 
rosery  was  as  follows : 

"  The  priest  with  a  cross  went  to  search  the  leper,  conducted  him 
personally  to  the  church  where  he  held  mass,  under  the  cloth  of 
the  dead.  At  Amiens  as  a  sign  of  renouncement  of  the  world  the 
leper  lay  for  a  certain  period  in  a  grave.  B}'  his  admission  the  leper 
lost  his  civil  rights.  He  could  neither  devise  nor  possess.  His  mar- 
riage was  annulled.  If  he  had  children  of  tender  age,  they  were  sep- 
arated from  him,  to  avoid  contagion,  but  his  wife  might  remain  with 
him  if  she  wished. 

"  He  received  a  gray  calemot,  a  great  coat,  a  claquet  to  warn  persons 
of  his  presence,  a  hood,  and  a  sort  of  scarlet  epaulet. 

''  The  lepers  were  compelled  to  wear  a  visible  sign  by  which  they 
might  be  distinguished.  No  inmate  of  a  leper  hospital  was  allowed 
to  enter  the  town  of  Castres  unless  he  had  a  white  cloth  around  his 
neck  and  a  claquet,  or  rattle,  with  which  to  make  a  noise  to  warn 
people  of  his  approach.  A  high  sack  or  a  hood  was  also  part  of  his 
vestment.  Not  only  the  lepers,  iDut  those  in  charge  of  them,  were 
compelled  to  wear  some  dress  of  distinctive  mark. 

"  The  members  of  the  grand  Betra  establishment  of  lepers  were 
compelled  to  wear  on  their  dress  a  capital  L  of  red  cloth,  one-half  a 
foot  long,  over  the  left  breast,  and  this  because  they  were  in  fre- 
quent contact  with  lepers  and  might  communicate  the  disease. 

"  Both  male  and  female  lepers  took  the  name  of  brother  and  sister 
and  lived  in  community.  They  were  compelled  to  receive  communion, 
hear  mass,  live  purely  and  chastely ;  their  expulsion  was  the  conse- 
quence of  grave  infraction.  The  leproseries  had  then  a  religious 
character;  they  were  of  a  true  monastic  order  by  compulsion,  it  is 
true,  and  not  by  volition.  But  it  should  not  be  forgotten  that  in  the 
Middle  Ages  the  monastic  state  was  regarded  as  enviable. 

"  The  lepers  had  their  subsistence  assured.  They  had  money  for 
their  small  expenses.  They  were  not  submitted  to  claustration.  In 
the  regulations  of  the  leproseries  there  were  disciplinary  measures ; 
the  most  severe  was  expulsion.  The  leprosery  was  not  then  an 
inferno,  as  in  that  case  the  expulsion  would  not  have  been  considered 
a  chastisement.  The  best  evidence  of  this  is  the  considerable  num- 
ber of  false  lepers  which  it  was  necessary  to  evict." 

Ambroise  Pare  has  reported  the  history  of  an  unfortunate  tuber- 
cular leper,  whose  ulcers  were  simply  painted  to  insure  his  entrance. 
This  practice  of  simulation,  almost  incredible  as  it  may  appear,  is  by 
no  means  extinct.     In  mv  observations  of  leprosy  in  the  Sandwich 


636  MORROW— LEPROSY. 

Islands  I  found  that  occasionallj'  natives  from  one  motive  or  another, 
sometimes  to  join  their  friends  or  familj',  will  endeavor  to  simulate 
the  disease  in  order  to  be  sent  to  the  leper  settlement.  With  an 
irritant  they  will  produce  discolorations  of  the  skin  which  resemble 
the  port-wine  discolorations  characteristic  of  the  beginning  stage. 
This  is  often  most  artisticall}'  done,  and  the  simulation  is  most  de- 
ceptive. 

In  consigning  a  leper  to  the  leprosery  an  examination  was  made 
by  a  jur\"  consisting,  at  Laon,  for  example,  of  a  doctor,  a  surgeon, 
and  an  apothecary. 

The  signs  of  leprosy  were  divided  into  uuivocal  and  equivocal. 
According  to  Chauliac  and  B.  de  Gordon,  the  uni vocal  signs  were 
"  roundness  of  the  eyes,  loss  of  the  eyebrows,  dilatation  of  the  nostrils, 
with  narrowness  of  the  summit,  a  raucous  voice,  alteration  of  the  lips, 
the  fixed  regard  of  the  satyr  (the  beast  of  horrible  aspect  in  which 
are  the  said  signs)." 

The  equivocal  signs  were  "  tuberosities  of  the  flesh,  the  color  of 
morphcea,  atrophy  of  the  muscles,  stupor  and  insensibility,  creeping 
of  the  flesh.  The  blood  is  black,  granular,  salt  clings  on  the  skin  of 
the  leper,  water  adheres  to  it  like  oil." 

Ambroise  Pare  thus  describes  the  method  of  examination  made  by 
a  jury  of  surgeons,  of  which  he  was  a  member,  to  ascertain  if  X.  was 
a  leper  (1583).  The  repoii;  is  as  follows:  "In  the  first  place,  we 
found  the  color  of  his  visage  blotched  and  pimpled  and  full  of  bluish 
spots,  then  we  plucked  hairs  from  his  beard  and  his  eyebroAvs  and 
found  that  a  small  portion  of  flesh  was  attached  to  the  root  of  the 
hair.  In  the  eyebrows  and  the  lower  part  of  the  ears  we  found 
small  tubercles,  the  brow  wrinkled,  the  expression  fixed  and  immo- 
bile, the  reddish  eyes  flaring,  the  nostrils  enlarged  without  and  con- 
tracted within,  as  if  obstructed  with  small  encrusted  ulcers,  the 
tongue  swollen  and  black,  and  above  and  beneath  we  found  thin 
small  grains  as  one  sees  in  measly  pigs,  the  gums  corroded,  and  the 
teeth  denuded,  and  the  breath  offensive,  having  a  rough  voice,  speak- 
ing through  his  uose.  We  also  saw  him  naked  and  found  tlie  sur- 
face of  his  flesh  rough  and  unequal,  like  that  of  a  thin-plucked  fowl, 
and  in  certain  places  many  dartres.  Besides  we  punctured  pro- 
foundly with  a  needle  the  tendon  of  the  heel  without  his  feeling 
pain.  By  all  these  signs,  unequivocal  and  equivocal,  we  declared 
that  X.  is  a  confirmed  leper." 

So  rapid  was  the  increase  of  leprosy  that  in  the  time  of  Louis 
VIII.  there  were  in  France  two  thousand  leper  houses,  and  the  num- 
ber in  Europe,  without  counting  those  in  Eussia  and  Sweden,  was 
nineteen  thousand. 


METHODS  OF  DEALING  WITH   LEPEOSY  IN  ANCIENT  TIMES.  637 

In  England,  Scotland,  and  Ireland  isolation  was  enforced  and  ren- 
dered possible  by  the  multiplication  of  lazarettos  all  over  tlie  country. 
Tlie  churcli  regarded  the  leper  dead,  and  performed  the  burial  ser- 
vice for  him  on  the  day  he  was  separated  from  his  fellow-creatures 
and  confined  in  the  lazaretto.  The  priest  went  with  the  cross  to  the 
house  of  the  condemned  leper,  and  consoled  him  for  the  incurable 
plague  with  which  God  had  stricken  him,  and  then  the  condem  ned  was 
conducted  to  the  church,  the  usual  burial  hymn  being  sung  on  his 
way  thither.  The  parents,  friends,  and  neighbors  joined  in  the  hide- 
ous cortege  which  rendered  the  last  honors  to  this  living  cadaver. 
Upon  reaching  the  church,  he  was  clothed  in  a  funeral  pall,  and  while 
placed  before  the  altar  between  two  trestles  the  mass  for  the  dead 
was  celebrated  over  him.  After  this  service  he  was  again  sprinkled 
with  holy  water  and  led  to  the  house  or  hospital  des-tined  for  his 
future  home,  where  he  was  comj)elled  upon  entering  to  take  the  vows 
of  obedience,  poverty,  and  chastity.  A  pair  of  clappers,  a  stick, 
a  cowl,  and  a  gray  habit  were  given  to  him. 

Before  leaving  the  leper  the  priest  solemnly  forbade  him  to 
appear  in  public  without  his  leper's  gown  to  warn  people  who  did 
not  know  him  to  flee  his  company,  or  to  enter  inns,  mills,  churches, 
and  bakehouses.  He  was  forbidden  to  enter  any  inn  or  habitation 
other  than  the  one  in  which  he  dwelt,  and  when  he  wished  wine  or  meat 
it  was  brought  to  him  in  the  middle  of  the  street,  or  to  touch  chil- 
dren or  to  give  them  what  he  had  touched,  to  wash  his  hands  or 
anything  pertaining  to  him  in  the  common  fountains  or  streams, 
or  to  drink  from  them  except  in  a  special  cup,  to  touch  in  the  market 
the  goods  he  wished  to  buy  except  with  his  stick,  and  in  asking  alms 
he  was  always  to  sound  his  rattle ;  he  was  forbidden  to  eat  or  drink 
with  any  other  than  lepers,  and  especially  to  walk  in  narrow,  paths 
or  to  answer  those  who  spoke  to  him  in  the  roads  or  streets,  lest  he 
should  infect  those  whom  he  might  meet  by  his  pestilential  breath 
and  with  the  infectious  odor  which  came  from  his  body.  Before 
leaving  the  leper  forever  to  the  seclusion  of  the  lazar  house  the  priest 
terminated  the  separation  from  his  fellow-creatures  by  throwing  upon 
the  body  of  the  leper  a  shovelful  of  earth  in  imitation  of  the  closure 
of  the  grave. 

Upon  the  death  of  the  leper  his  habitation  was  burned,  and  he 
himself  was  buried  with  his  face  to  the  earth.  In  many  places  the 
corpses  of  lepers  were  found  in  this  posture. 

Dr.  Newman,  in  his  prize  essay  on  leprosy,  refers  to  many 
curious  laws  relating  to  the  lepers  in  England  and  Scotland.  He 
characterizes  them  as  curiously  contrary  and  extravagant,  some  being 
so  mild  and  indefinite  as  to  be  useless,  others  so  strict  and  severe  as 


638  MORROW— LEPROSY. 

to  be  cruel  and  impossible  to  keei),  aud  concludes  that  "  strict  segre- 
gation as  understood  and  practised  uowada^'S  never  entered  tiie  minds 
of  those  desiring  to  separate  lepers  from  the  health}-." 

The  religious  duties  forced  upon  inmates  under  the  control  of  the 
church  were  of  the  most  monastical  character.  During  Lent  all  the 
brothers  as  well  as  sisters  were  obliged  to  receive  discipline  three 
dsijs  in  the  week.  Disobedient  members  were  punished  at  the  dis- 
cretion of  their  prior  aud  prioress  by  corporeal  correction,  aud 
offenders  who  refused  to  submit  to  the  usual  discipline  were  reduced 
to  bread  and  water,  and  after  the  third  offence  they  were  liable  to  be 
ejected. 

No  inmate  was  allowed  to  transgress  the  bounds  or  to  attempt  to 
go  beyond  the  walls  of  the  hospital  without  his  close  cape,  or  to  stand 
or  walk  by  any  king's  road  before  or  after  service.  By  a  decree  of 
the  Archbishop  of  Canterbury  (1200)  lepers,  when  forming  a  large 
colon 3%  were  entitled  to  have  their  own  church  and  graveyard,  but  in 
many  places  this  special  church  and  graveyard  were  quite  impossible 
through  lack  of  funds  and  lack  of  lepers.  In  many  places  arrange- 
ments were  made  by  which  the  lepers  were  enabled  to  take  some 
share  in  the  church  services  by  means  of  the  leper  window  or  squint 
window  or  hagioscope.  There  were  generally  openings  or  apertures 
in  the  wall  or  narrow,  oblong  slits  through  which  the  elevation  of  the 
Host  at  the  high  altar  and  other  ceremonies  might  be  viewed  with- 
out the  lepers  themselves  being  seen  by  the  congregation.  Certain 
churches  also  had  a  st(jue  slab  let  into  the  sill  of  the  window  and  so 
placed  that  a  leper  could  receive  the  sacrament  without  actual  con- 
tact with  the  administrator. 

By  the  laws  of  England  lepers  were  classed  with  idiots,  mendi- 
cants, outlaws,  etc.,  as  incapable  of  being  heirs. 

In  both  Britain  and  Normandy  lepers  were  expelled  from  society, 
and  had  no  power  to  alienate  their  effects  or  dispose  of  them  to  any 
one.     They  were  regarded  as  dead. 

It  would  appear  that  the  means  provided  for  the  sustenance  of 
the  lepers  were  not  of  a  very  abundant  character.  The  lepers  were 
allowed  to  go  where  they  chose  and  beg  what  they  could  or  reside  in 
any  leper  hospital  to  which  they  could  get  admittance. 

A  regulation  in  support  of  the  hospitals  all  over  the  land  states 
that  tainted  beef  is  to  be  sent  to  the  leper  house  in  the  neighborhood, 
and  if  there  was  not  one,  then  it  was  to  be  destroyed.  Then  again, 
when  a  wild  beast  was  found  wounded  or  dead  in  the  forest  it  was  to 
be  sent  to  the  nearest  leper  hospital. 

Many  hospitals  were  supported  by  voluntary  or  compulsory  con- 
tributions of  a  certain  toll  ujjon  everything  carried  to  the  markets. 


METHODS   OF   DEALING  WITH   LEPROSY   IN   ANCIENT  TIMES.  639 

Other  establishments  were  financed  bv  means  of  fairs  in  which 
the  chief  articles  for  sale  were  wool,  meal,  hops,  hardware,  etc. ,  and 
on  one  day  horses.     The  business  transacted  was  very  extensive. 

In  the  hospital  at  Edinbm-gh  it  seems  that  the  lepers  were  kept  in 
the  home,  and  between  dawn  and  sundown  the  lepers  took  turn  in 
sitting  at  the  gate  asking  alms,  which  were  put  in  their  cups.  The 
allowance  was  only  four  shillings  a  week  for  each  inmate. 

At  the  hospital  in  the  city  of  Glasgow  the  inmates  were  allowed  to 
go  out  of  the  hospital,  drawing  attention  by  means  of  their  clapper, 
and  asking  alms. 

The  number  of  leper  houses  in  England,  Scotland,  and  Ireland 
was  over  two  hundred.  "  The  number  of  these  lazar  houses,  however 
great,  was  insufficient  to  accommodate  more  than  a  small  proportion 
of  those  suffering  from  the  disease." 

In  a  majority  of  these  leper  houses,  if  a  man  was  married,  the  wife 
was  allowed  to  go  with  him.  As  early  as  789,  Charlemagne  promul- 
gated laws  forbidding  the  marriage  of  lepers.  A  similar  law  was 
passed  in  Great  Britain  hj  the  Welsh  king,  Hywel  Dda,  who  died  in 
950,  and  there  are  acts  of  Parliament  which  forbid  cohabitation  if 
either  wife  or  husband  is  a  leper,  the  leper  in  these  circumstances 
being  considered  as  dead. 

In  1757  leprosy  was  declared  to  be  a  valid  cause  for  divorce  in 
France.  In  1776  a  law  was  passed  in  Iceland  to  prevent  lepers  from 
marrying. 

As  early  as  1488  there  was  an  edict  ordering  all  lepers  to  leave 
Paris. 

In  England  in  the  fourteenth  century,  according  to  Simpson,  a 
leprous  woman  with  a  child  was  buried  alive,  and  in  1746  lepers  were 
driven  from  London. 

The  harsh  measures  used  in  Europe  for  the  suppression  of  leprosy 
have  always  been  regarded  as  an  illustration  of  the  value  of  segrega- 
tion. Strict  segregation,  if  we  are  to  trust  to  historical  evidence, 
was,  however,  never  carried  out,  as  the  inmates  of  most  of  the  leper 
homes  were  not  strictly  confined,  but  were  allowed  to  leave  the  hos- 
pitals and  beg  in  the  street,  and  thus  mingle  with  their  feUow- 
beings. 

Nevertheless  leprosy  decreased  in  a  most  remarkable  manner. 
In  the  thirteenth  century  the  disease  reached  its  zenith  in  Europe. 
In  the  fourteenth  century  it  had  commenced  to  decline  throughout 
Europe,  and  by  the  end  of  the  sixteenth  century  it  had  practically 
disappeared. 

Dr.  Newman  is  inclined  to  attribute  the  decline  and  final  extinction 
of  endemic  leprosy  in  England  and  Scotland,  not  to  segregation,  but 


640  MORROW — LErROSY. 

to  the  tendencj'  of  leprosy  to  die  out  und6r  the  more  favorable  hy- 
gienic conditions,  good  food,  and  improved  sanitation. 

It  is  stated  that  formerly  in  China  more  drastic  measures  were 
used  for  the  suppression  of  leprosy  than  now  prevail. 

Dr.  B.  Taylor,  of  Fuh  Ning  Fuh  Chow,  in  China,  states  that, 
while  there  are  lepers  in  the  vicinity,  there  are  none  in  the  town  it- 
self, and  that  in  a  small  village  a  mile  from  the  city  a  village  hospital 
still  exists,  but  there  are  no  lepers  in  it.  Concerning  this  assertion 
Dr.  Taylor  has  been  told  that  a  mandarin,  about  sixty  years  ago,  desir- 
ous of  stamping  out  leprosy,  having  invited  all  the  lepers  to  a  feast  in 
the  hospital,  surrounded  it  with  soldiers  and  then  set  it  on  lire. 

Richard,  in  his  history  of  Tonquin,  states  that  leprosy  is  so  com- 
mon in  Tonquin  that  there  are  pieces  of  land  assigned  where  those 
attacked  by  it  must  reside.  Thej'  are  shut  out  from  society,  and  it  is 
even  lawful  to  kill  them  if  they  enter  cities  or  towns. 

In  Damascus  the  fear  of  detection  is  stated  to  have  compelled 
lepers  either  to  live  in  communities  in  huts  outside  of  the  village  or 
to  seek  refuge  in  leper  houses  in  the  city. 

In  comparatively'  recent  times  a  leper  house  has  been  discovered  in 
Bagdad  surrounded  by  a  thick  wall,  with  a  little  room  in  which  all 
the  lepers  ^vere  compelled  to  retire. 

In  Rhodes  they  are  said  to  have  been  banished,  destroyed,  or  sent 
to  some  uninhabited  island  to  subsist  as  best  they  could. 

In  Finland  lepers  were  at  one  time  isolated  in  houses  built  on 
islands  in  the  lake,  and  on  the  death  of  the  leper  the  house  and  all 
its  furniture  were  burned.  Similar  leper  huts  were  found  by  Savory 
in  Caudia,  and  Boeck  discovered  them  in  the  island  of  Siera. 

In  Europe  the  leper  houses  were  abandoned  because  of  the  grad- 
ual decrease  and  final  extinction  of  the  disease,  but  it  is  worthy  of 
note  that  in  other  countries  leper  houses  and  hospitals  have  fallen 
into  disuse  or  been  abolished  from  indifference  on  the  part  of  author- 
ities or  from  a  lack  of  confidence  in  their  utility.  For  example,  in 
Iceland  towards  the  middle  of  the  sixteenth  century  four  leper  houses 
were  erected  in  four  quarters  of  the  island.  In  1848  the  leper  hos- 
pitals were  abolished.  It  is  worthy  of  note,  however,  that  during  the 
past  year  (1898)  a  leper  hospital  has  been  built  at  Reikiavik. 

In  various  portions  of  China,  in  Java,  as  well  as  in  North  and 
South  America,  lazarettos  which  were  formerly  used  for  the  isolation 
of  lepers  have  fallen  into  disuse.  The  San  Lazaro  Hospital,  which 
was  founded  in  Mexico  by  Cortez,  the  conqueror,  was  abolished  about 
thirty -five  or  forty  years  ago,  although  there  has  been  no  sensible 
decrease  observed  in  the  disease. 

The  decline  of  the  epidemic  of  leprosy  in  Norway  is  cited  as  an 


METHODS   OF  DEALING  WITH   LEPROSY   IN   MODERN  TIMES.  641 

evidence  of  the  value  of  segregation.  Since  the  establishment  of  the 
leper  hospitals  3,400  lepers  have  been  admitted,  while  during  the 
same  period  5,053  new  cases  have  appeared.  The  total  number  of 
known  lepers  in  1856  was  2,870,  and  in  1896  only  688.  In  1885  a  law 
was  passed  making  the  segregation  of  lepers  compulsory,  but  it  is 
understood  that  if  a  leper  is  able  to  provide  himself  with  a  separate 
bed,  cooking  and  eating  utensils,  and  have  his  clothes  separately 
washed,  he  is  not  compelled  to  enter  the  leper  hospital. 

In  Norway  isolation  is  by  no  means  absolute.  The  doors  and 
gates  of  the  hospital  are  not  kept  locked,  and  the  inmates  may  some- 
times be  met  in  the  neighboring  roads,  those  who  have  no  ulcerations 
being  allowed  to  go  out.  They  are  kept  in  on  market  days.  At 
Trondhjem  and  other  places  they  are  permitted  to  enter  houses  and 
churches  or  come  in  contact  with  other  people. 

In  the  island  of  Cyprus  the  effect  of  isolation  is  seen  in  the  fact 
that  previous  to  1878  there  were  150  lepers  in  the  island,  120  of  whom 
have  been  placed  in  the  leper  island ;  of  these  57  have  died  and  63 
remain.  At  the  end  of  ten  years  there  were  not  more  than  30  lepers 
outside  of  the  hospital,  the  whole  number  in  the  island  not  exceeding 
100,  showing  a  decrease  of  one-third  during  this  comparatively  short 
period  (Thin). 

In  1896  the  British  Government  passed  a  bill  to  provide  for  the 
segregation  of  pauper  lepers  and  the  control  of  lepers  following  cer- 
tain callings  which  extended  to  the  whole  of  British  India. 

It  is  worthy  of  note  that  no  person  is  termed  a  leper  unless  he  is 
suffering  from  a  variety  of  leprosy  in  which  the  process  of  ulceration 
has  commenced,  and  the  provision  of  the  act  extends  only  to  a  leper 
who  has  in  a  public  place  solicited  alms  or  exposed  or  exhibited  any 
sores,  wounds,  bodily  injuries,  or  deformities  with  the  object  of  excit- 
ing charity  or  obtaining  alms.  Such  person  may  be  sent  to  a  leper 
asylum,  where  he  shall  be  detained  until  discharged  by  order  of  the 
board. 

The  leper  is  prohibited  from  pursuing  any  of  the  following  call- 
ings :  (a)  Practice  as  a  medical  practitioner,  work  as  a  barber,  wash- 
woman, water-carrier,  baker,  tailor,  haberdasher,  or  domestic  servant; 
(b)  selling  any  food,  drink,  or  drug  for  human  consumption;  (c)  bath- 
ing at  a  stream  or  drinking  at  any  drinking-fountain,  well,  tank,  or 
reservoir;  (d)  riding  in  any  public  conveyance. 

Violation  of  any  of  these  acts  is  punishable  by  a  fine  not  exceed- 
ing fifty  rupees. 

In  the  Straits  Settlements  a  leper  may  be  removed  upon  an  order 
from  the  senior  magistrate  to  the  nearest  detention  ward  or  other 
building  authorized  for  the  reception  of  lepers. 
Vol.  XVIII.— 41 


642  MORROW— LEPROSY. 

A  further  act  in  1897,  entitled  a  warrant  to  amend  the  law  relating 
to  lepers,  prohibits  the  leper  from  following  any  of  the  callings  men- 
tioned above. 

Vagrant  lepers  may  be  sent  to  the  leper  asjdum  and  detained  until 
released  by  order  of  the  Government. 

A  further  p>rovisiou  of  the  same  act  makes  it  lawful  for  the  com- 
missioner to  undertake  the  registration  and  visitation  of  lepers  within 
the  municipal  limits.  The  landing  of  lepers  is  prohibited,  and  the 
master  of  a  vessel  from  which  such  a  leper  is  lauded  i.s  lial^le  to  a  fine 
not  to  exceed  8500.  Lepers  uulawfullj^  landed  ma}-  be  sent  to  the 
leper  asylum  or  returned  to  the  jjlace  whence  they  came. 

In  the  Cape  of  Good  Hoi)e  an  act  was  passed  in  1884  to  "  check 
the  spread  of  the  disease  known  as  lepros}'." 

Any  person  suffering  from  "  infectious"  lei)rosy  shall,  after  exam- 
ination by  the  district  surgeon  and  by  another  duly  qualified  medical 
I^ractitioner,  be  removed  to  a  hospital  for  lepers,  therein  to  be  con- 
fined according  to  the  provisions  of  the  law.  This  was  amended  in 
1890,  and  infectioiis  leprosy  was  defined  as  "  leprosy  in  an  advanced 
and  grievous  stage,  whether  embraced  in  the  loss  of  auj^  member  of 
the  body  or  any  other  mark  of  the  disease."  A  distinction  was  made 
between  such  cases  of  lepros}'  as  are  advanced  and  likely  to  be  of 
immediate  danger  to  other  persons  and  such  cases  as  are  less  ad- 
vanced, and  separate  provisions  were  made  for  dealing  with  cases  of 
the  one  kind  and  the  other.  Indian  immigrants  and  certain  others 
afilicted  with  leprosy  were  to  be  sent  back  to  their  own  country. 
Male  and  f -male  lepers  were  to  be  entirely  separated  from  each  other 
while  in  the  hospital.  No  communication  or  intercourse  could  be 
allowed  between  the  persons  confined  in  a  hospital  or  location  for 
lepers  and  j^ersons  not  confined  tlierein  Except  the  attendants  of  the 
hosjntals,  although  the  leper  had  the  pri%'ilege  of  seeing  his  friends 
and  legal  advisers  at  reasonable  times. 

The  leprosy  law  was  amended  in  1894,  permitting  any  person  oi 
persons  belonging  to  the  family  or  relatives  of  the  person  about  to  be 
committed  in  the  leper  location  to  go  with  the  leper,  provided  that 
in  case  of  minors  accompanying  such  leper  the  consent  of  the  guar- 
dian or  parent  may  be  taken  on  behalf  of  such  minors. 

In  1892  a  law  was  passed  for  the  extermination  and  repression  of 
the  disease  of  leprosy  in  British  Bechuanaland,  which  ju'ovides  for 
the  report  of  cases,  the  power  of  removal  to  the  asylums,  the  creation 
of  separate  male  and  female  asylums,  and  the  power  of  removal  to  the 
asylum  at  the  Cape  of  Good  Hope. 

In  the  Seychelles  vagrant  and  pauper  lepers  may  be  removed  to 
the  lei)er  asylum.     It  is  lawful,  however,  to  grant  the  apj)lication  of 


JMETHODS   OF   DEALING   WITH   LEPEOSY   IN   MODERN  TIMES.  643 

any  next  of  kiu  or  friend  that  such  lejDer  be  delivered  to  such  next  of 
kin  or  friend  and  entrusted  to  his  keeping. 

The  laws  applying  to  Queensland,  New  South  Wales,  and  other 
Australian  settlements  are  practically  the  same.  In  addition  the  lep- 
rosy act  of  New  South  Wales  (1890)  provides  for  the  obligatory  notifica- 
tion of  cases  of  leprosy ;  for  the  detention  and  isolation  of  lepers,  the 
estabKshment  of  lazarettos,  and  other  purposes.  In  Queensland  the 
leprosy  act  of  1892  .provides  that  when  any  case  of  leprosy  or  sup- 
posed leprosy  is  not  rei:iorted  by  the  medical  jn-actitioner  under 
whose  observation  it  comes,  he  shall  be  liable  to  a  fine  not  exceed- 
ing £100. 

In  Jamaica  there  was  a  leper  asylum  law  passed  in  1896  which 
provides  for  the  arrest  of  lepers  wandering  about  begging  and  their 
consignment  to  the  leper  asylums.  If  the  leper  can  furnish  security 
for  his  proper  maintenance  and  provide  treatment,  he  may  be  dis- 
charged from  the  asj'lum. 

The  laws  in  regard  to  the  employment  of  4)ersons  affected  with 
leprosy  are  as  follows :  That  he  shall  not  be  employed  in  the  prepa- 
ration or  sale  of  any  article  which  concerns  the  food,  drink,  or  the 
clothing  of  the  public  in  general,  and  shall  not  follow  the  occufjation  of 
a  barber,  washer  of  clothes,  cigar  and  cigarette  maker,  tobacco  manu- 
facturer, or  school  teacher.  Such  person  or  the  person  who  employs 
him  shall  be  liable  to  a  fine  not  exceeding  £5,  and  in  default  of 
payment,  to  imprisonment  with  or  without  hard  labor  for  a  period 
not  exceeding  three  months. 

In  the  Leper  Act  for  Barbadoes  in  1890  there  is  provision  made 
for  the  voluntary  entrance  into  the  leper  asylum  of  any  one  suffering 
from  the  disease,  and  the  compulsory  entrance  of  those  who  seek 
alms  or  support  or  who  are  without  any  visible  means  of  subsist- 
ence. 

In  the  Islands  of  St.  Christopher,  Nevis,  Antigua,  Trinidad,  and 
Tobago,  the  provisions  of  the  different  acts  affecting  leprosy  are  about 
the  same.  Lepers  have  the  privilege  of  entering  the  leper  asylums, 
and  there  is  compulsory  segregation  of  mendicant,  pauper,  and 
obnoxious  lepers. 

In  British  Guiana  essentially  the  same  provisions  are  made. 
Leper  vagrants  who  are  found  wandering  abroad  begging  alms,  seek- 
ing pecuniary  support,  or  exposing  their  leprous  sores  in  any  public 
road  may  be  conveyed  to  the  leper  asylum.  Lepers  may  be  dis- 
charged on  security  being  given  for  their  treatment  in  private. 

In  Cuba  and  Porto  Eico  there  are  hospitals  for  the  care  of  lepers, 
but  entrance  is  not  compulsory. 

In   the  Island '  of  Malta,  the  laws  for  checking   the  spread  of 


644  MORROW — LEPROSY. 

leprosy  are  to  the  effect  that  any  person  found,  upon  the  examina- 
tion of  the  medical  board,  composed  of  five  physicians,  three  of 
whom  shall  be  in  the  service  of  the  Government,  to  be  suffering  from 
leprosy  shall  be  removed  to  the  asylum  for  lepers,  to  be  there  de- 
tained during  the  whole  period  of  the  disease.  It  is  provided,  how- 
ever, that  anj"  person  detained  in  the  asylum  may  leave  the  asylum 
for  the  purpose  of  fixing  his  residence  abroad. 

In  the  island  of  Cyprus  the  leper  laws  of  1891  make  various  pro- 
visions for  the  isolation  of  all  persons  who  are  found  upon  ex- 
amination of  three  qualified  medical  practitioners  to  be  suffering 
from  the  disease  of  leprosy,  in  the  leper  asylum.  Lepers  may  build 
separate  dwellings  for  their  own  use  within  the  precincts  of  the  asy- 
lum grounds.  There  is  a  penalty  of  £5  for  not  giving  information  of 
the  existence  of  lepers. 

It  will  be  seen  from  the  section  on  "  Geographical  Distribution" 
that  leprosy  is  very  extensively  distributed  in  almost  all  the  French 
colonies.  In  New  Caledonia  it  has  been  j^ropagated  with  an  almost 
incredible  rapidity.  The  insurrection  of  1878  contributed  to  dissem- 
inate the  disease.  In  French  Guiana  leprosy  "  propagates  itself  with 
such  rapidity  that  one-tenth  of  the  population  is  infected."  Ac- 
cording to  Jeanselme,  Tunis,  Senegal,  the  coast  of  Guinea,  and  the 
French  Congo  are  all  contaminated,  but  there  are  no  accurate  docu- 
ments giving  reliable  statistics. 

While  numerous  lejiroseries  have  been  established  in  various  parts 
of  these  colonies,  strict  isolation  or  segregation  is  nowhere  practised. 
A  decree  of  the  French  Government  in  1840  decided  that  the  situation 
demands  the  segregation  of  every  free  person  who  is  attacked.  A 
new  decree  was  promulgated  in  1841.  It  provides  that  "  there  will  be 
admitted  to  the  leprosery  at  I'Acarouuay  all  persons  diseased  with 
leprosy  who  may  make  the  demand,  and  that  there  will  be  sent  there 
all  those  who,  being  recognized  as  attacked  with  leprosy,  have  no 
means  of  taking  care  of  themselves."  Persons  in  good  circumstances 
who  wish  to  be  treated  at  home  at  their  own  expense  may  be  isolated 
at  a  distance  of  two  kilometres  at  least  from  Cayenne  and  one  kilo- 
metre from  villages.  Unfortunately  the  provisions  of  the  laws  for  the 
control  of  lei)ros3"  in  the  French  colonies  have  never  been  strictly 
enforced. 

In  1893  there  was  promulgated  for  New  Caledonia  a  decree  almost 
identical  with  that  of  French  Guiana.  These  are  the  only  French 
colonies  where  there  has  been  established  any  regulation  of  leprosy. 

The  United  States. — In  this  country  the  Government  has  taken  no 
active  measures  respecting  the  prevention  of  leprosy  bej-ond  quaran- 
tine regulations  with  a  view  of  preventing  the  immigration  of  persons 


METHODS   OF  DEALING  WITH  LEPROSY  IN  MODERN  TIMES.  645 

affected  witli  the  disease.  These  regulations  promulgated  by  the 
Treasury  Department  through  the  United  States  Marine-Hospital  ser- 
vice in  1894  provide  "that  vessels  arriving  at  quarantine  with  lep- 
rosy on  board  shall  not  be  granted  pratique  until  the  leper,  with  his 
or  her  baggage,  has  been  removed  from  the  vessel  to  the  quarantine 
station.  No  case  of  leprosy  will  be  landed.  If  the  leper  is  an  alien 
and  a  member  of  the  crew,  and  the  vessel  is  from  a  foreign  port,  said 
leper  shall  be  detained  at  quarantine  at  the  vessel's  expense  until 
taken  aboard  by  the  same  vessel  when  outward  bound." 

Many  years  ago  the  people  of  California  recognized  the  danger  of 
the  introduction  of  leprosy  on  the  Pacific  coast  through  Chinese  immi- 
gration. Section  2,952  of  the  Penal  Code  provides:  "It  shall  not 
be  lawful  for  lepers  or  for  persons  affected  with  leprosy  or  elephan- 
tiasis to  live  in  ordinary  intercourse  with  the  population  of  this  State. 
But  all  persons  shall  be  compelled  to  inhabit  such  lazarettos  or  leper 
quarters  as  may  be  assigned  to  them  by  the  Board  of  Supervisors  by 
the  city  or  county  in  which  they  may  be  domiciled  or  settled.  And 
the  Board  of  Supervisors  are  vested  with  power  and  are  required  to 
•  make  all  necessary  provision  for  the  separation,  detention,  or  care  of 
lepers  or  persons  affected  with  leprosy  or  elephantiasis  settled  or 
domiciled  in  their  respective  cities  or  counties." 

Section  2,955  provides  for  the  inspection  of  all  persons  arriving  in 
California  from  foreign  ports  by  the  Commissioner  of  Immigration. 
Those  found  to  be  lepers  are  to  be  taken  in  charge  by  him  and  placed 
in  a  suitable  lazaretto,  and  there  detained  separate  from  the  general 
population  so  long  as  they  shall  elect  to  remain  in  the  State,  or  until 
they  shall  have  recovered,  bat  they  are  allowed  to  return  whence 
they  came.  The  master  or  consignee  of  the  vessel  bringing  lepers 
is  liable  to  a  penalty  of  $1,000  for  failing  or  refusing  to  comply  with 
the  law. 

Additional  laws  were  passed  in  1883,  forbidding  the  landing  of 
lepers  from  any  ship,  their  transfer  to  another  vessel,  or  their  har- 
boring by  any  person  outside  the  lazaretto. 

While  there  is  ample  legislation  in  California  for  the  segregation 
of  lepers,  the  health  authorities  in  many  towns  are  exceedingly  lax 
about  enforcing  the  laws. 

In  Oregon  the  health  officers  for  the  different  ports  are  required 
to  board  all  vessels  arriving  by  sea  ancl  to  examine  passengers  and 
crews  for  leprosy,  but  there  is  no  provision  for  the  detention  and  care 
of  lepers. 

Louisiana  is  the  only  State  in  the  Union  which  has  provided  a 
home  or  asylum  especially  for  lepers.  In  1892  there  was  passed  by 
the  legislature  "  an  act  to  prevent  the  spread  of  leprosy  and  provide 


646  MOREOW — LEPROSY. 

treatment  for  the  same  and  for  isolation  of  persons  afflicted  with  said 
disease  and  j)enaltie8  for  non-compliance  with  the  provisions  of  this 
act."  This  act  was  supplemented  by  one  in  1894  which  ordered  that 
"all  persons  afflicted  or  suifering  with  said  disease  of  leprosy  shall 
be  confined  in  an  institiition  isolated  and  used  for  the  treatment  of 
said  disease."  Notification  of  all  cases  of  leprosy  was  required  under 
penalty  of  fine  or  imi)risonment.  Pursuant  to  the  provisions  of  this 
act  a  home  was  established  (1895)  in  Iberville  Parish,  about  eighty 
miles  from  New  Orleans.  During  the  first  year  of  its  existence 
thirty-one  lepers  were  transported  to  the  home,  twenty -three  of  whom 
were  born  in  Louisiana.  Since  then  a  few  additional  cases  have  been 
admitted,  but,  owing  to  the  apathy  of  the  profession  and  the  public, 
the  provisions  of  the  above  acts  have  not  been  successfully  carried 
out. 

In  Massachusetts  the  boards  of  health  are  empowered  to  isolate  and 
provide  necessary  attention  to  persons  afflicted  with  le])rosy  or  other 
sicknesses  dangerous  to  the  public  health. 

The  Board  of  Health  of  New  York  has,  under  the  general  provision 
of  the  chapter  relating  to  diseases  which  in  the  opinion  of  the  board 
shall  be  dangerous  to  the  public  health,  the  power  to  isolate  leprosy. 
Several  years  ago  the  New  York  Board  of  Health  began  to  take  official 
cognizance  of  leprosy  in  this  city.  All  lepers  coming  within  their 
jurisdiction  were  isolated  on  North  Brother  Island.  At  first  they 
were  quartered  in  a  tent  on  the  island  as  far  removed  as  possible  from 
the  other  buildings.  Later  a  cabin-like  structure  was  erected  for 
their  confinement,  from  which  they  were  transferred  and  quarantined 
in  one  of  the  disused  buildings  for  contagious  diseases.  In  1897  the 
few  lepers  in  confinement  on  North  Brother  Island  were  allowed  to 
esca])e,  and  since  then  there  has  been  no  official  action  on  the  part  of 
the  Board  of  Health  in  reference  to  lepers  in  this  city. 

Many  other  of  the  individual  States  have  made  laws  afi'ecting  the 
control  of  lepers  within  their  respective  Ix  rders,  and  the  national 
Government  exercises  no  jurisdiction  over  them. 

There  was  passed  Jauuary  24tli,  1898,  by  the  Congress  of  the  United 
States,  an  act  for  the  investigation  of  leprosy,  which  provides  that  the 
Su[)ervising  Surgeon  General  of  the  Marine-Hospital  service,  under  the 
direction  of  the  Secretary  of  the  Treasury,  shall  ai)point  a  commission 
of  medical  officers  of  the  Marine-Hospital  service  to  investigate  the 
origin  and  prevalence  of  leprosy  in  the  United  States  and  to  decide 
upon  what  legislation  is  necessary  for  the  prevention  and  the  spread  of 
this  disease.  So  far  as  can  be  ascertained"  no  active  ste])S  have  been 
taken  to  carry  the  ])rovisions  of  this  act  into  effect. 

Haioaii. — In  1863  the  health  authorities  became  alarmed  at  the 


GEOGEAPHICAL  DISTEIBUTION.  647 

rapid  spread  of  leprosy  in  the  Hawaiian  Islands,  and  in  1865  the  legis- 
lative assembly  passed  an  act  to  prevent  the  spread  of  leprosy,  wliicli 
provided  for  the  gathering  together  of  all  the  lepers  of  the  kingdom, 
with  a  view  to  their  isolation  and  treatment.  The  execution  of  this  act 
was  entrusted  to  the  ♦Hawaiian  Board  of  Health.  A  portion  of  land 
was  set  apart  on  the  island  of  Molokai  for  the  seclusion  of  the  lepers, 
and  a  hospital  for  the  reception  and  examination  of  the  lepers  was 
established  at  Kaliki,  near  Honolulu. 

The  method  adopted  by  the  sanitary  authorities  in  dealing  with 
leprosy  is  as  follow^s :  The  authorities  are  empowered  to  bring  all 
suspected  lepers  to  the  hospital  for  examination.  The  examination 
takes  place  under  the  supervision  of  the  board  of  three  physicians,  who 
are  selected  for  their  especial  fitness  for  this  task.  Those  suspected  of 
leprosy  are  kept  under  surveillance  until  either  the  suspicious  symj)- 
toms  have  disappeared  or  unmistakable  signs  of  leprosy  are  manifest. 
The  pronounced  lepers  are  kept  secluded  and  forwarded  to  the  leper 
settlement  to  remain  there  until  they  die. 

Nearly  all  the  lepers  sent  to  the  Molokai  settlement  have  passed 
through  the  receiving  station.  In  the  earlier  times  some  occasionally 
were  sent  there  direct  from  other  islands. 

Since  the  establishment  of  the  leper  settlements  over  six  thousand 
lepers  have  been  received. 

Geographical  Distribution. 

Asia. 

India. — India  has  always  been  regarded  as  one  of  the  chief  and 
oldest  centres  of  leprosy.  It  is  exceedingly  difficult  to  ascertain 
whether  leprosy  is  on  the  increase  or  decrease,  as  in  many  districts 
there  are  no  reliable  data  upon  which  to  base  an  accurate  estimate  as 
to  the  prevalence  of  the  disease.  Vague  and  widely  differing  esti- 
mates have  been  given.  According  to  the  investigations  of  the  com- 
missioners of  the  national  leprosy  fund,  who  were  sent  to  India  to 
investigate  and  report  upon  leprosy,  there  were  over  one  hundred 
thousand  lepers  in  India.  Little  has  been  done  in  the  way  of  legis- 
lation or  in  the  systematic  management  of  lepers;  probably  not  two 
per  cent,  receive  proper  care.  A  leper  asylum  known  as  the  Matoonga 
Hospital  has  been  recently  established  near  Bombay,  with  accom- 
modations for  three  hundred  inmates,  entrance  into  which  is  volun- 
tary. There  are  a  number  of  other  hospitals  in  which  lepers  may 
receive  care  and  attention. 

The  census  of  1891  gives  114,239  lepers  in  India,  a  proportion  of 
0.5  per  thousand.     There  is  in  the  presidency  of  Bengal  0.51  per 


648  MORROW — LEPROSY. 

thousand;  in  Madras,  0.37  per  thousand;  in  Bombay,  0.47  per  thou- 
sand; in  Lower  Burmah,  0.63;  in  Upper  Burmah,  1.18  per  thousand; 
in  Mj'sore  and  Coorg,  0.16  per  thousand.  In  single  districts,  Bam- 
koora  and  Berhoom  and  Bengal,  there  are  3.63  to  3.52  per  thousand. 
The  island  of  Ceylon  has  about  two  thousand  lepers — 1.10  per  thou- 
sand. 

In  certain  regions  leprosy  is  much  more  prevalent  than  in  others. 
Dr.  Van  Dyke  Carter  found  that  from  one-third  to  one-half  of  all  the 
districts  are  affected  with  leprosy  in  variable  proportions ;  in  some 
the  ratio  was  two  lepers  in  one  thousand  inhabitants,  and  as  high  as 
one  in  two  or  three  hundred  people,  or  one  in  eighty,  or  even  one  in 
fifty  existed  in  certain  parts. 

The  opinion  of  the  Leprosy  Investigation  Committee  was  to  the 
effect  that  the  available  data  point  strongly  to  a  decrease  in  the  dis- 
ease and  that  leprosy  does  not  prevail  in  India  to  such  an  extent  as  to 
constitute  a  general  or  universal  danger. 

China. — Although  China  is  one  of  the  oldest  and  most  prolific  hot- 
beds of  leprosy  in  Asia,  it  is  impossible  to  obtain  accurate  statis- 
tics of  the  prevalence  of  the  disease.  The  traditional  policy  of  the 
Chinese,  observed  in  their  exclusiveness  and  their  disposition  to 
thwart  outside  investigation  into  their  customs,  habits,  and  manners 
of  living ;  the  enormous  extent  of  their  territory,  much  of  it  unex- 
plored or  unknown  to  modern  civilization ;  and  the  teeming  population 
(one-fifth  of  the  human  race),  constitute  conditions  which  preclude 
the  possibility  of  obtaining  accurate  information.  The  general  state- 
ment that  leprosy  prevails  throughout  the  whole  empire  of  China 
would  seem  to  be  contradicted  by  recent  investigations. 

Cantlie,  in  his  prize  essay  on  "Leprosy  in  China,  Indo-China, 
Malaya,  the  Archipelago,  and  Oceanica"  (New  Sydenham  Society, 
1897),  says  that  not  one-third  of  the  territory  of  China  is  under  the 
ban  of  leprosy.  It  is  certain  that  leprosy  does  not  prevail  in  the 
north  of  China  to  anything  like  the  extent  it  prevails  in  the  south- 
eastern parts.  In  endeavoring  to  arrive  at  the  precise  facts,  based 
upon  the  most  reliable  data,  it  is  necessar\'  to  comjjare  the  notes  of 
various  observers  and  carefully  sift  the  evidence.  For  exami)le,  the 
statement  was  quoted  in  a  prize  essay  of  the  national  leprosy  fund, 
by  Dr.  George  Newman,  that  "  at  Tientsin  there  are  two  large  asylums 
for  wretches  who  are  taken  with  lepros}',  located  on  the  outside  of 
the  cit}-;  two  or  three  hundred  lepers  live  at  each  of  these  asylums." 
Dr.  Cantlie's  investigations  show  that  there  are  no  leper  hospitals  at 
Tientsin. 

Likewise  it  was  stated  by  von  Bergmann  that  Hanoi,  the  capital  of 
Tonquin  (one  hundred  thousand  inhabitants),  in  ludo-China,  was  so 


GEOGEAPHICAL  DISTRIBUTION.  649 

infected  by  leprosy  fcliat  one-lialf  of  the  inhabitants  were  lepers.  The 
truth  is  that  in  the  leper  village  not  far  from  Hanoi  one-half  of  the 
four  hundred  inhabitants  were  lepers. 

In  the  province  of  Shantung  there  are  a  few  lepers  in  almost 
every  village,  more  in  the  interior  than  on  the  coast.  In  Hupeh 
and  Szechuen  leprosy  is  more  or  less  prevalent.  In  the  province  of 
Fokien  it  is  a  veritable  scourge. 

The  province  of  Kwantung  is  called  by  Cantlie  the  cradle  of 
leprosy.  In  Kwantung  there  is  a  leper  village  near  every  large 
town  in  the  province.  There  were  formerly  two  leper  asylums  near 
Canton,  one  with  seven  or  eight  hundred  inhabitants,  the  other  over 
a  thousand.  At  present  there  is  but  one  leper  village  one  and  one- 
half  miles  outside  of  Canton  with  six  hundred  and  fifty  inhabitants. 
In  addition  to  the  lepers  in  this  village  several  hundred  dwell  in  the 
river  on  boats.  In  the  district  and  port  of  Swatow,  situated  at  the 
mouth  of  the  Han  Eiver,  which  serv,es  as  a  place  of  embarkation  for 
the  enormous  coolie  trade  of  the  densely  populated  regions  of  this  pro- 
vince, leprosy  prevails  extensively.  In  this  district  there  are  villages 
called  leper  settlements,  but  there  is  no  segregation,  and  lepers  are 
allowed  to  move  about  freely. 

In  Macau,  a  Portuguese  settlement  in  Kwantung  province,  lepers 
are  segregated  on  an  almost  inaccessible  island,  and  the  character  of 
the  coast  acts  as  a  natural  barrier  against  leper  deserters.  They  are 
not  sent  here  until  the  disease  is  quite  far  advanced. 

During  Dr.  Cantlie's  visit  there  were  in  the  leper  island  forty 
males  and  twenty-nine  females.  The  proportion  of  Portuguese  of  the 
entire  population  affected  with  the  disease  would  be  about  one  per 
thousand. 

The  island  of  Hainan  has  a  large  proportion  of  lepers  among  its 
Chinese  population.     The  aborigines  are  exempt. 

In  the  island  of  Hong-Kong  leprosy  is  more  or  less  prevalent.  In 
two  and  one-half  years  one  hundred  and  twenty-five  lepers  presented 
themselves  for  treatment  at  the  Alice  Memorial  Hospital.  Before 
the  annexation  of  the  island  by  the  British  leper  families  and  com- 
munities lived  in  huts  on  the  hiUs  about  the  town  and  maintained 
themselves  by  begging  or  otherwise.  Since  the  British  occupation, 
whenever  a  leper  is  suspected,  the  police  arrest  him,  and  if  he  should 
prove  leprous  he  is  sent  away  to  the  mainland.  It  is  worthy  of  note, 
Jiowever,  that  a  minimum  calculation  shows  that  in  seven  years,  from 
1880  to  1886,  at  least  six  or  seven  hundred  lepers  dwelt  in  the  island 
of  Hong-Kong  unknown  to  the  Government. 

In  the  island  of  Formosa  many  of  the  Chinese  population  are 
lepers,   but  the  Japanese  are  exempt.     In  the  peninsula  of  Korea 


660  MORROW— LErEOSY. 

leprosy  is  most  prevalent  iu  the  south  and  dies  away  to  the  north. 
All  the  cases  met  with  iu  the  north  are  importations. 

Dr.  Cantlie  says:  "Leprosy  in  the  far  East  is  centred  iu  the 
sontheastern  provinces  of  China.  The  coolie  emigrants  come  chiefly 
from  Kwautung  and  Fokien ;  three-quarters  of  the  coolif  emigrants 
from  China  are  from  these  i^ro^-inces,  and  the  spread  of  leprosy  in 
the  Malay  peninsula,  iu  the  Dutch,  Spanish,  and  Portuguese  East 
Indies,  and  in  Oceanica,  has  been  in  all  cases  coincident  and  concur- 
rent with  the  immigration  and  residence  of  coolies  from  these  prov- 
inces. In  no  instance  over  this  vast  area  has  any  native  acquired 
leprosy  except  where  Chinese  coolies  have  settled." 

The  natives  ascribe  leprosy  to  the  Chinese  immigrants,  and  the 
name  used  shows  the  belief  in  the  Chinese  origin  of  the  disease. 
There  is  no  native  name  for  the  disease  in  the  alioriginal  languages, 
except  in  Malay. 

The  Chinese  recognize  thirty-two  kinds  of  leprosy ;  the  two  prin- 
cipal forms,  which  they  term  "moist"  and  "dry,"  corresponding  to 
the  tubercular  and  anaesthetic  types.  The  causes  assigned  for  leprosy 
are  almost  innumerable.  They  believe  in  the  hereditary  transmission 
of  leprosy,  but  believe  that  the  disease  does  not  go  beyond  the  third 
generation.  They  attach  a  great  importance  to  sexual  intercourse  iu 
the  spread  of  leprosy.  In  most  ])rovinces  they  think  that  the  efHuvia 
from  the  patient  are  sufficient  to  transmit  the  disease.  When  a  leper 
quits  his  seat,  another  person  will  not  hesitate  to  occupy  it,  but  be- 
fore the  newcomer  sits  down  he  will  fan  the  place  where  the  leper  sat 
as  precaution  against  infection.  The  Chinese  in  some  provinces 
believe  that  leprosy  is  caused  by  a  microscopic  animal  which  flies 
unseen.  A  person  is  stated  to  have  been  beaten  with  a  stick  smeared 
with  blood  from  a  leper,  and  to  have  died  subsequently  from  lei:)rosy. 
The  urine  tainted  with  leprosy  is  stated  to  have  been  the  means  of  in- 
fecting healthy  persons.  Compulsory  segregation  is  practised  only 
by  the  Portuguese  in  Macau. 

The  methods  used  by  the  Chinese  for  the  segregation  of  their 
lepers  is  by  the  establishment  of  asylums  or  settlements  termed  leper 
villages.  Each  asylum  is  under  the  control  of  a  head  man,  who  must 
reside  at  the  institution  and  who  is  nominall}^  or  really  a  leper  who 
manages  the  general  affairs  of  the  asylum,  reporting  from  time  to 
time  to  the  district  authority  the  condition  of  the  establishment,  ad- 
missions, deaths,  etc.  A  small  stipend  is  allotted  to  the  lepers  by 
the  Government,  which  they  supplement  by  begging  in  the  streets, 
and  thus  eke  out  the  means  of  a  miserable  existence.  When  a  deper 
dies,  his  corpse  is  burned,  as  fire  is  supposed  to  destroy  the  insects 
which  cause  the  disease.     The  leper  villages  are  not  isolation  estab- 


GEOGEAPHICAL  DISTRIBUTION.  651 

lisliments,  but  merely  refuges  where  lepers  may  dwell.  Tlie  majority 
are  beggars  who  daily  go  forth  to  obtain  alms.  They  are  met  with 
in  shops  and  streets,  on  the  river,  everywhere.  These  dwellers  in 
the  leper  villages  mix  with  the  crowd,  handle  the  food  exhibited  for 
sale,  and  pay  the  cash  they  carry  in  their  leprous  hands.  Nobody 
refuses  to  buy  from  a  leprous  huckster,  and  provisions  are  bought 
fearlessly  in  the  store  of  a  leper  (Ashmead).  Cantlie  says:  "The 
leper  village  they  dwell  in  serves  merely  as  a  hotbed  of  infection,  and 
the  disease  will  remain  endemic  so  long  as  these  nests  of  infection  are 
maintained." 

Cochin.  China. — Leprosy  also  extensively  prevails  in  Indo-China, 
in  Siam,  Annam,  Gamboge,  and  in  Tonquin.  At  the  gates  of  Saigon 
at  Tinghe  there  is,  according  to  M.  Jeanselme,  a  leprosery  containing 
from  two  hundred  to  two  hundred  and  fifty  i:)atients.  At  Tonquin  lep- 
rosy is  rare  in  the  mountainous  regions  which  are  but  little  inhabited. 
The  leprous  village  of  Hanoi  is  situated  in  a  depression.  It  is 
isolated  by  a  high  dike,  pools,  and  impenetrable  bamboo  thickets. 
Half  of  its  four  hundred  inhabitants  are  lepers.  There  is  a  smaller 
leper  village  in  the  city  of  Hanoi,  and  tlie  leper  mendicants  freely 
traverse  the  streets  of  the  capital.  The  disease  is  quite  widely  spread 
among  the  Annamites.  Segregation  is  extensively  practised.  Lepers 
are  not  isolated  in  the  villages,  but  live  in  separate  localities  from  one 
another  and  take  part  in  ordinary  labor  as  if  they  were  not  diseased. 
In  certain  regions,  however,  they  are  segregated  very  vigorously. 
They  are  compelled  to  keep  away  from  frequented  roads  and  to  follow 
special  paths. 

Malay  Peninsula.  — In  Singapore,  which  is  the  headquarters  of  the 
British  Government  of  the  Straits,  there  is  a  large  and  well-ax)pointed 
leper  hospital.  The  inmates  are  chiefly  Chinese,  but  a  number  of 
■  Malays,  a  few  Portuguese,  and  occasionally  some  other  European  are 
met  with  among  them.  There  is  also  a  large  leper  asylum  in  Penang. 
Most  of  the  cases  are  imported  from  other  countries,  principally 
China.  Another  leper  hospital  is  at  Johore.  In  all  these  hospitals 
the  Chinese  form  the  largest  number  of  the  patients. 

In  Perak  leprosy  is  widespread,  both  Malays  and  Chinese  being 
extensively  affected.     None  of  the  Japanese  are  known  to  be  lepers. 

In  Muar  leprosy  is  uncommon.  Chinese  suffer  mostly,  Malays 
rarely. 

Butch  East  India.— In  Malaysia  leprosy  has  its  principal  seat 
in  the  islands  of  Java,  Sumatra,  and  the  island  of  Borneo,  although 
other  portions  of  the  Dutch  East  Indies  are  infected. 

Broes  van  Dort,  as  also  Cantlie,  insists  that  the  propagation  of 
the  disease  is  especially  due  to  the   immigration  of  the   Chinese. 


652  MOBROW— LEPROSY. 

Tliere  are  in  Central  Java  30  to  38  patients ;  in  Western  Java,  42 ;  in 
Eastern  Java,  2,703;  upon  the  east  coast  of  Sumatra  about  1,000; 
and  upon  the  west  coast,  156.  In  the  island  of  Java  tlie  disease  has 
taken  on  dangerous  proportions.  Up  to  1865  there  were  fourteen 
hospitals.  In  1886  there  were  six  voluntary  asylums  for  lepers. 
The  inmates  are  principally  Chinese,  who  are  everywhere  the  chief 
sufferers.  The  few  Europeans  when  attacked  have  returned  to  Hol- 
land. Since  the  introduction  of  European  civilization  leprosy  is  said 
to  have  increased,  as  formerly  the  Javanese  killed  their  lepers  or 
exposed  them  so  that  they  should  perish  from  lack  of  nourishment. 
The  Malucca  Islands  and  the  Islands  of  Amunta  and  Tarnacte  are  also 
infected. 

The  Philippine  Islands. — There  are  no  data  of  a  definite  character 
accessible  as  to  the  prevalence  of  lei:)rosy  in  the  Philippine  Islands. 
There  are  leper  hospitals  near  Manila.  One  hospital  in  Luzon  has 
one  hundred  and  fifty  beds.  The  general  impression  is  that  the  cases 
which  were  the  origin  of  local  epidemics  of  leprosy  in  Valencia  and 
Alicante,  Spain,  were  imported  from  the  Philippines. 

Japan. — We  have  no  knowledge  of  the  origin  of  leprosy  in  Japan. 
The  general  impression  is  that  it  has  existed  in  this  country  for  cen- 
turies, at  least  six  hundred  years  before  the  Christian  era,  and  that  the 
disease  was  formerly  more  severe  in  its  ravages  than  it  is  now.  Ac- 
cording to  the  latest  official  communication,  based  ujoon  the  investiga- 
tions of  the  Sanitary  Bureau  of  the  Home  Office,  there  were  in  Japan 
(in  September,  1897)  23,647  lepers  distributed  through  the  empire. 
Leprosy  is  more  prevalent  on  the  coast  than  in  the  mountainous 
regions  of  Japan.  There  is  no  attempt  at  government  control  of  lep- 
rosy, and  leprosy  asylums  or  hospitals  have  never  existed.  In  many 
instances  the  families  themselves  have  a  separate  room  for  the  leper 
member.  People  regard  the  disease  as  hereditary  and  do  not  marry 
members  of  a  leprous  family.  The  lepers  intermarry  among  them- 
selves. 

Australia. — There  is  no  official  record  of  leprosy  in  any  part  of  the 
Australian  continent  prior  to  1885.  Dr.  Ashburton  Thompson,  in  his 
contribution  to  the  "  History  of  Leprosy  in  Australia"  (London,  1897), 
gives  a  chronological  summary  of  all  cases  of  leprosy  in  Australia 
which  had  been  recorded.  They  amounted  to  70  in  New  South  Wales, 
45  in  Victoria,  48  in  Queensland,  2  in  Western  Australia,  and  19  in 
the  Northern  Territories.  Of  the  New  South  Wales  cases,  34  occurred 
among  the  whites.  The  large  majority  of  the  lepers  in  Australia  have 
been  Chinese  and  Kanakas  (South  Sea  Islanders).  The  Chinese, 
however,  are  at  present  the  most  numerous. 

There  is  no  record  of  leprosy  among  the  aborigines  in  any  ex- 


GEOGEAPHICAL  DISTRIBUTION.  65'6 

plored  part  of  the  continent  before  the  known  advent  of  emigrants  with 
recognized  leprosy ;  but  that  they  are  susceptible  to  the  disease  has 
been  proven  by  the  breaking  out  of  leprosy  among  them  since  1892. 
Dr.  Thompson's  table  shows  a  general  increase  of  recorded  cases  sub- 
sequent to  1877.  It  also  shows  a  marked  increase  of  cases  subsequent 
to  legislation  for  the  control  of  leprosy  in  these  colonies.  For  exam- 
ple, in  thirty-one  years  before  compulsory  notification  was  established 
there  were  in  certain  districts  seventy-two  cases.;  in  four  years  after 
compulsory  notification  sixty-three  cases  were  recorded.  He  thinks 
that  there  is  probably  no  such  increase  as  would  appear  from  these 
tables.  The  proportionately  larger  number  which  have  been  recorded 
within  the  last  feAV  years  is  due  to  the  greater  attention  which  is  given 
the  disease.  The  most  stringent  laws  extant  against  leprosy  have 
been  enacted  in  Australia. 

In  JVeiv  Zealand  many  cases  have  been  discovered  among  the 
Maoris;  both  Chinamen  and  whites  have  also  been  affected.  The 
disease  is  said  to  be  declining. 

In  the  Samoan  Islands  leprosy  has  been  introduced  within  recent 
years,  but  its  spread  has  been  comparatively  restricted. 

In  the  Fiji  Islands  one  per  cent,  of  the  inhabitants  are  lepers. 
Of  twenty -one  cases  reported  by  Dr.  Corney,  eleven  were  in  Indians; 
the  others  were  in  natives  of  other  islands,  Solomon,  Tonga  Islands, 
but  there  were  no  cases  among  the  Europeans.  The  increase  of  lep- 
rosy in  the  Fiji  Islands  of  late  years  has  been  attributed  to  the  abo- 
lition of  the  practice  of  privately  killing  affected  persons,  which  was 
in  vogue  before  the  British  rule. 

New  Caledonia  is  one  of  the  most  important  and  extensive  of  the 
modern  centres  of  leprosy.  The  disease  is  said  to  have  been  brought 
in  by  the  Chinese,  although  its  introduction  may  possibly  have 
been  through  other  sources.  A  Chinaman  in  1866  or  1868  had  been 
received  by  a  tribe  of  Kanakas  with  whom  he  had  lived  for  several 
years.  His  body  and  extremities  were  covered  with  hideous  sores. 
Within  ten  years,  according  to  the  missionaries,  several  analogous 
cases  wore  observed  among  the  natives  who  had  been  previously  ex- 
empt from  the  disease.  In  1880  five  New  Hebrides  islanders  were 
found  to  be  suffering  from  the  disease,  and  in  1883  numerous  lepers 
were  found  on  the  north  coast  of  tlie  island. 

After  the  insurrection  of  1878  and  the  dispersion  of  the  tribe  the 
malady  was  propagated  with  astonishing  rapidity  through  the  entire 
colony.  It  is  estimated  that  at  least  four  thousand  Kanakas  have 
been  affected  with  leprosy  in  New  Caledonia.  In  1886  ten  foreigners 
had  contracted  the  disease ;  three  years  later  forty-six  had  been  at- 
tacked ;   and  this  estimate  Dr.  Grail  says  is  much  below  the  actual 


654  MORROW— LEPROSY. 

number.  There  are  three  leproseries  provided  for  the  patients,  but 
there  is  no  strict  isolation.  The  lepers  of  this  archipelago  were  segre- 
gated at  the  leproseries  of  the  Marquisas  Islands,  which  contain  about 
four  hundred  lepers. 

Northern  and  Central  A'iia. — Little  is  known  of  leprosy  in  Central 
Asia.  From  Northern  China  it  extends  up  to  Kamschatka  and  up 
the  land  of  the  Jakats.  It  is  slightly  prevalent  in  Siberia  and  also 
prevails  among  the  Kouts.  Smirnow  stated  that  in  the  province  of 
Vilinisk  there  were  in  1891  seventy-seven  lepers  in  a  population  of 
about  seventy  thousand. 

In  Persia  and  in  Turkestan  little  is  known  of  the  facts  in  regard  to 
lejiros}',  except  that  it  ]jrevails  more  or  less  extensively'  in  certain 
provinces.  According  to  Munsch,  the  proportion  is  about  one  per 
thousand  and  in  some  districts  one  per  hundred  among  the  inhabitants 
of  Turkestan. 

In  Asiatic  Turkej'  the  disease  exists  in  Syria,  Arabia,  Asia 
Minor.  In  Asia  Minor,  according  to  von  During,  the  proportion  of 
lepers  is  about  one  per  thousand  of  the  inhabitants. 

Leprosy  prevails  in  all  Palestine.  The  principal  centres  are  at 
Jerusalem,  Pvamleh,  and  Naplouse,  near  Jerusalem.  The  leprosery 
of  Byr  About  Jesus  Hilfe  contains  about  thirty-four  patients. 
Another  small  hospital  has  six  or  eight  inmates.  The  total  number 
of  lepers  in  Jerusalem  is  said  to  be  forty  to  fifty.  The  Araljs  are 
the  principal  sufi'erers,  the  Christians  and  Jews  being  comparatively 
exempt.  The  patients  rarely  enter  the  asylum  in  the  earlier  stage  of 
the  disease,  but  remain  with  their  family  and  friends  until  they  become 
helpless. 

Africa. 

Egypt  has  always  been  regarded  as  one  of  the  oldest  centres  of 
leprosy.  The  oflBcial  census  which  was  made  by  Engel  gives  as  the 
result  a  total  of  2,204  lepers  in  1893.  This  number  is  evidently 
very  much  below  the  exact  figure.  The  disease  is  encountered  prin- 
cipally in  the  delta  and  in  the  Upper  Nile  regions.  The  present 
Khalifa,  according  to  the  press  reports,  is  suffering  from  leprosy,  con- 
tracted by  taking  the  wife  of  an  emir  who  died  of  leprosy.  It  is  met 
with  in  Abyssinia,  in  Darfur,  and  along  the  east  coast  line  of  Africa. 

It  is  found  in  Madagascar,  Mauritius,  Isle  of  Pieuuion,  Santa 
Maria,  and  in  the  Seychelles,  In  the  island  of  Eeunion  there  is 
a  leproserj'  in  which  the  number  of  patients  varies  between  seventy 
and  one  hundred. 

In  JIadagascar,  according  to  Davidson,  the  disease  has  extended 
since  the  old  laws  of  isolation  were  abolished. 


GEOGRAPHICAL  DISTRIBUTION.  655 

In  German  East  Africa  leprosy  prevails  less  upon  tlie  coast  than 
in  the  neighborhood  of  the  Great  Lakes,  where  it  is  quite  extensive, 
and  in  certain  islands  of  the  Victoria  Nyanza.  Here  the  Government 
established  a  leprosery  (Metento),  where,  in  1895*  18  casqs  had  been 
admitted.  In  South  Africa  leprosy  for  the  past  fifty  years  has  shown 
a  marked  increase  (Impey). 

Gaj^e  Colony. — According  to  the  most  authentic  records,  leprosy 
existed  among  the  earliest  races  which  inhabited  this  continent.  In 
South  Africa,  according  to  tradition,  leprosy  has  always  existed 
among  the  Bushmen.  On  account  of  the  custom  of  the  natives  of 
abandoning  their  sick  or  driving  them  in  the  forests  to  die  of  hunger, 
the  disease  was  liept  in  rejjression. 

According  to  Dr.  Isaacs,  the  Bantas,  including  the  Kaffir  tribes, 
with  whom  the  earlier  settlers  came  in  contact  in  1750,  occujjied  a 
large  part  of  the  African  continent.  Leprosy  was  a  disease  well 
known  to  them  and  had  existed  as  far  back  as  their  traditions  went. 
They  likewise  had  the  custom  of  putting  out  of  the  way  their  sick  and 
helpless. 

The  earliest  ofiicial  records  of  leprosy  occur  in  the  year  1756,  dur- 
ing the  Dutch  rule.  Early  in  the  present  century,  in  the  year  1817, 
the  first  asylum  for  lepers  was  established  by  European  missionaries 
at  Hemel  en  Arde.  Four  hundred  patients  were  admitted  from  1817  to 
1846.  Later  another  asylum  was  established  at  Graf-Einet.  In 
1846  the  two  asylums  were  closed,  and  the  lepers  transferred  to  Eob- 
ben  Island.  In  1889  a  compulsory  segregation  act  was  put  in  force, 
owing  to  the  notable  increase  in  leprosy.  The  total  number  of  lepers 
admitted  to  Eobben  Island  from  1846  to  1897  was  1,948.  There  are 
in  Cape  Colony  at  the  present  time  812  lepers ;  in  Basutoland,  250 
lepers ;  in  Griqualand  East  and  in  the  Transkeian  district,  650  cases ; 
in  Bechuanaland,  10  cases ;  in  Natal,  200  lepers ;  in  the  Orange  Free 
State,  150  cases ;  in  the  Transvaal  Eepublic,  105  cases. 

German  Southwest  Africa  is  up  to  the  present  time  believed  to  be 
free  from  leprosy.  The  disease  is  encountered  in  the  Congo  State, 
but  not  extensively.  Most  of  the  cases  are  met  with  in  the  lower 
Congo.  It  is  unknown  to  the  Kamerun;  the  estuary  of  the  Niger 
seems  to  be  also  free  from  the  disease,  but  it  is  found  on  the  Gold 
Coast,  Sierra  Leone  in  Senegambia,  and  in  the  Canary  Islands.. 
Stamford,  in  TJie  Journal  of  Tropical  Medicine  (No.  31),  reports  15 
cases  of  leprosy  in  the  Canary  Islands.  Dr.  Goldsmith  estimates 
that  in  Madeira  there  are  about  70  cases,  or  six  to  10,000  inhabitants. 
There  has  been  a 'sensible  decrease  in  the  disease  in  the  past  thirty 
years.  Tonkin  has  never  observed  leprosy  in  the  coast  between  Sierra 
Leone  and  Old  Calabar.     Lepers  are  found  in  vast  numbers  upon  the 


656  MORROW— LEPROSY. 

Upper  Niger  and  along  the  Benin  River.  Leprosy  also  prevails 
quite  extensively  in  Maroc. 

Algeria. — Gemy  and  Raynaud  report  having  observed  58  cases 
of  leprosy  in  Algerki.  Of  these  about  40  were  in  Algiers ;  the  others 
lived  at  Constantiue  and  other  places.  This  number  of  cases  rei)orted 
is,  in  their  opinion,  very  much  below  the  actual  number.  The  Span- 
iards brought  the  disease  from  Alicante  and  Valencia,  in  which  region 
there  exists  a  considerable  leprosy  centre.  Some  of  the  patients  were 
afflicted  with  the  disease  at  the  time  of  their  arrival  in  Algiers.  In  a 
great  number  it  was  manifest  only  after  a  residence  of  from  three  to 
twenty  years. 

Among  the  number  there  were  8  Jews,  which  represents  a  propor- 
tion of  1  per  1,000,  as  there  are  8,000  Jews  in  Algeria. 

Europe. 

The  countries  of  Central  EurojDe  have  for  the  most  part  been  free 
from  leprosy  since  the  decline  and  extinction  of  the  great  epidemic  in 
the  sixteenth  and  seventeenth  centuries.  Within  the  past  two  cen- 
turies onh^  occasional  cases  have  been  met  with  here  and  there,  and  in 
these  for  the  most  part  the  patients  have  contracted  the  disease  in  for- 
eign countries  where  leprosy  is  endemic. 

Great  Britain. — As  a  result  of  a  careful  and  painstaking  investiga- 
tion Dr.  Phineas  Abraham,  of  London,  reported  to  the  Berlin  Lep- 
rosy Congress  that  the  total  number  of  cases  of  leprosy  of  which  he 
could  find  records  in  England,  Scotland,  and  Ireland  was  56,  14  of 
which  were  personal  cases.  He  had  reason  to  believe  that  there  were 
about  20  more  under  the  observation  of  medical  men,  who  for  various 
reasons  were  unable  to  furnish  notes  of  their  cases.  Estimating  a 
margin  of  about  20  unrecognized  cases,  he  concludes  that  the  num- 
ber of  cases  of  lei:»ros3'  occurring  during  the  last  ten  years  in  Great 
Britain  and  Ireland  does  not  exceed  96,  or  certainly  not  more  than 
100.  He  concludes  that  there  is  no  reason  to  believe  that  there 
are  more  lepers  in  the  United  Kingdom  now  than  for  many  years 
past. 

Jonathan  Hutchinson,  who  sees  more  cases  of  rare  diseases  than 
an}^  other  man  in  London,  says  that  "  cases  of  leprosy  are  fewer  now 
than  formerly."  All  of  the  cases  above  mentioned  contracted  the  dis- 
ease in  India  and  in  countries  where  leprosy  is  endemic.  The  only 
cases  recorded  in  this  century  in  which  the  disease  must  have  been 
communicated  in  England  are  the  cases  of  Dr.  Hawtre^'  Benson  and 
Dr.  Liveing,  and  a  case  published  in  Guy's  Hospital  Reports  for 
1868.     From  time  to  time  supposed  cases  have  been  reported  which 


GEOGKAPHICAL  DISTEIBUTION.  657 

upon    investigation    proved  to    have   been   examples   of   erroneous 
diagnosis. 

Holland,  Belgium,  Denmark,  Sivitzerland,  Germany,  and  Austria 
are  practically  leprosy  free.  In  Holland  tliere  are  30  cases  (Broes  van 
Dort);  in  Belgium  there  are  4  cases  (Bayet) ;  in  Denmark  there  are 
from  1  to  3  cases  (Ehlers);  in  Switzerland  there  are  2  cases  (Jadas- 
sohn) ;  in  Germany  there  are  33  cases  (Blascho). 

In  Germany  there  has  been  noted  within  the  past  few  years  quite 
an  epidemic  around  Memel,  a  village  near  the  Kussian  frontier,  sup- 
posed to  have  been  brought  in  from  the  province  of  Cracow,  in  Rus- 
sian Poland.  The  epidemic  which  began  in  1873  has  attacked  32 
persons ;  of  these  16  were  imported  and  16  acquired  in  the  locality 
in  which  the  patients  live.  Nineteen  of  the  lepers  have  died.  The 
Memel  epidemic  is  regarded  by  leprologists  as  affording  an  admir- 
able opportunity  for  studying  the  direct  contagiousness  of  leprosy — 
brother  to  sister,  daughter  to  mother,  mistress  to  servant,  servant  to 
mistress,  etc. 

'  In  Austria-Hungary  the  disease  is  sporadic  in  Bosnia  and  Herze- 
govina. The  official  report  states  there  are  133  lepers,  which  number 
is,  according  to  the  reporter,  vastly  below  the  actual  number. 

In  Montenegro  about  1,000  to  2,000  of  the  inhabitants  have  the 
disease.     Almost  the  entire  Isle  of  the  Vulcrans  is  infected. 

In  Servia  and  Bulgaria  there  are  only  a  few  cases  reported  (104 
tubercular  and  29  anaesthetic  cases),  but  the  indications  are  that  the 
disease  is  quite  prevalent. 

Boumania. — Drs.  Petrini  and  Kalindero  reported  to  the  Leprosy 
Congress  the  existence  of  208  lepers  in  Boumania.  The  first  record 
of  its  existence  was  in  1874.  It  has  markedly  increased  since  the 
Eusso-Eoumania-Turkish  War  in  1877.  The  greatest  number  of 
lepers  are  found  along  the  roads  followed  by  the  Eussian  army  or  in 
the  neighborhood  of  those  roads. 

Constantinople. — Von  During  reports  that  he  has  personally  ob- 
served 258  lepers  and  estimates  the  entire  number  in  the  city  at  be- 
tween 500  and  600.  Zambaco  Pacha  estimates  that  there  are  4,000 
lepers  in  the  Ottoman  Empire.  In  Constantinople  the  Jews  are  the 
principal  sufferers.  The  Mussulmans  are  rarely  attacked,  their 
immunity  being  attributed  to  their  mode  of  living. 

Greece.— Bexgmsinii  estimates  the  number  of  lepers  upon  the  Gre- 
cian continent  at  about  400.  Zambaco  Pacha  gives  a  similar  esti- 
mate. During  the  war  Greece  received  a  large  number  of  lepers  from 
Crete,  augmenting  the  number.  The  statistics  of  leprosy  in  Greece 
presented  to  the  Berlin  Leprosy  Congress  differ  somewhat.  Eosolimos 
estimates  there  are  99  lepers ;  Mitaftsis  estimates  there  are  119  lepers. 
Vol.  XVIII.— 43 


658  MORROW— LEPllOSY. 

Samos  aud  other  islands  of  the  J^^^^eaii  Sea  are  also  infected.  Ehlers 
found  15  i:)atients  in  the  peninsula  of  Pelion  in  1897.  He  remarks 
that  when  one  searches  for  lepers  one  always  finds  more  than  are  uj^on 
the  official  lists. 

Maud  of  Crete. — According  to  Zambaco,  Crete  itself  contains 
from  2,000  to  3,000  lepers.  There  are  no  reliable  data  to  show  when 
leprosj^  was  introduced  into  the  island.  Dr.  Smart  in  1851-52  gave 
the  number  of  cases  in  the  leper  villages  as  625.  There  is  no  leper 
hospital  on  the  island,  nor  are  the  patients  subjected  to  any  govern- 
ment or  municipal  control.  The  fear  of  contagion  alone  compels  a 
semi-separation  of  the  lepers  in  the  three  leper  villages  situated  just 
outside  the  three  principal  towns.  In  1891  Dr.  Bilioti  estimated  the 
number  at  320  out  of  a  total  population  of  300,000,  the  number  of 
males  far  exceeding  that  of  the  females. 

Itahj. — There  are  no  definite  statistics  as  to  the  number  of  lepers 
in  Italy,  although  Pellizari  states  that  the  number  is  large.  Ferrari 
reported  several  years  ago  152  cases  in  Sicily .  Mazza  has  observed  20 
cases  in  Sardinia.  Breda  has  seen  24  cases  at  Commachio.  SmMl 
foci  of  the  disease  are  known  to  exist  in  various  parts  of  Italy.  The 
ancient  leprosery  of  San  Eemo,  which  is  regarded  as  the  last  remnant 
of  the  ancient  leproseries  in  Europe  during  the  Middle  Ages,  always 
contains  a  few  lepers.  Giovaunini  has  observed  at  Turin  since  1890 
13  Piedmontese  lepers.  Pellizari  states  that  these  figures  all  fall 
below  the  actual  number. 

Lepers  are  found  along  the  entire  Kiviera,  both  the  French  and 
the  Italian  Eiviera.  Jaja  reports  18  cases  in  Apulia.  Amicis  reports 
15  leprous  families  in  the  vicinity  of  Naples.  The  disease  is  scattered 
in  small  foci  throughout  almost  the  entire  country.  There  are  also 
lepers  in  tlie  islands  of  Elba,  Malta,  aud  Gozzo. 

Portugal. — Leprosy  prevails  extensively  in  this  peninsula.  Fal- 
cao  collected  statistics  of  468  lepers,  but  this  number  is  far  below  the 
actual  number.  He  estimates  that  the  actual  number  of  lepers  in 
Portugal  is  not  less  than  1,000.  Small  foci  of  the  disease  are 
scattered  here  aud  there ;  the  most  infected  centre  is  Lisbon.  There 
are  special  hospitals  for  lepers  at  Lisbon  and  at  Cordova,  but  there 
is  no  attempt  at  isolation.  These  hospitals  contain  a  small  number 
of  inmates,  who  are  free  to  enter  or  leave  as  they  wish.  Falcao  has 
since  collected  reports  of  772  cases. 

Spain. — M.  Olivade  estimates  that  there  are  from  1,000  to  1,500 
lepers  in  Spain,  500  of  whom  have  come  under  his  personal  observa- 
tion. The  disease  prevails  most  extensively  in  Galicia,  Asturia,  and 
Andalusia,  Granada  aud  Catalonia.  There  is  a  leprosery  at  Granada 
and  another  at  Seville,  the  latter  containing  40  patients.     Poucet  has 


GEOGEAPHICAL   DISTEIBUTION.  659 

recounted  the  list  of  lepers  and  tlie  origin  and  spread  of  the  disease 
in  1850  in  the  village  of  Parcent,  and  Zuriaga  gives  details  of  cases 
which  he  has  observed  to  the  number  of  66.  There  were  known  to 
be  in  1888  in  the  province  of  Valencia  69  lepers,  and  in  1893,  120, 

France. — There  are  leprosy  foci  at  Brest,  Bordeaux,  Marseilles, 
and  Toulon.  On  the  Mediterranean  coast  along  the  French  Kiviera 
small  foci  of  the  disease  are  found,  and  sporadic  cases  in  Brittanj'. 
There  are,  according  to  Hallopeau,  constantly  from  160  to  200  lepers 
in  Paris,  aU  of  whom  have  been  infected  in  foreign  countries.  It  is 
worthy  of  note  that  so  far  as  known  none  of  these  patients  has  pro- 
pagated the  malady. 

As-regards  leprosy  in  Iceland,  opinions  differ  whether  the  disease 
was  of  ancient  origin,  brought  by  the  Norwegians  in  settling  the  island 
in  874,  or  whether  it  was  brought  from  Norway  about  the  end  of  the 
thirteenth  century  with  the  return  of  the  crusaders.  Towards  the 
middle  of  the  sixteenth  century  leprosy  had  obtained  such  a  foothold 
as  to  attract  public  attention,  and  four  hospitals  were  erected  in  four 
quarters  of  the  island.  The  smallpox  epidemic  of  1707  destroyed 
more  than  one-third  of  the  population  and  with  them  the  greater  part 
of  the  leper  families.  In  1848  the  leprosy  hospitals  were  abolished. 
In  1889  Ehlers  personally  examined  102  cases ;  besides  there  were  42 
patients  living  at  too  great  a  distance  to  be  accessible ;  making  a  total 
of  144  cases.  Ehlers  in  his  second  voyage  to  the  island,  in  1895, 
unearthed  13  more  cases,  making  a  total  of  157.  In  1898  he  knew 
of  181  cases,  and  thought  that  the  number  exceeded  200.  Becently 
(1898)  a  new  leprosy  hospital  of  twenty  beds  has  been  established  in 
Iceland,  and  a  system  of  obligatory  notification  and  modified  isolation 
has  been  instituted. 

In  Finland  there  are  known  to  be  67  lepers.  In  1807  the  disease 
had  increased  to  such  an  extent  that  it  was  determined  to  isolate  the 
sufferers  in  order  to  x^revent  any  further  spread.  A  building  was 
erected  at  the  end  of  a  small  island  in  Lake  Kitajarvi,  and  the  lex^ers 
were  removed  thereto.     In  1845  the  hospital  system  was  abandoned. 

In  Sweden  there  are  known  to  be  from  70  to  75  patients,  of 
whom  30  are  isolated;  36  live  in  the  province  of  Hels^gland  and  15 
in  Dalarne. 

The  most  important  centre  of  leprosy  in  Europe  in  modern  times 
is  in  Norway.  Three  leproseries  have  been  established  in  Norway — 
the  Lungegaards  Hospital  in  Bergen  in  1857;  two  others  in  1861,  one 
in  Molde,  and  the  other  in  Throndhjem.  In  a  period  between  1857 
and  1895  there  were  admitted  to  these  hospitals  3,400  lepers,  while 
during  the  same  period  5,053  new  cases  of  leprosy  appeared. 

The  total  number  of  known  lepers  at  the  close  of  1856  was  2,870; 


360 


MORROW — LEPROSY. 


at  the  end  of  1895,  688.     The  followiug  table  gives  at  a  glance  evi- 
dence of  the  remarkable  decrease  in  leprosy  in  the  last  forty  years : 


New 
cases. 

Results. 

Year. 

1 
Died. 

Transferred 

to 
leproseries. 

Cured. 

Emi- 
grated. 

Total. 

liviDg 
at  home. 

1856    

1.157 

1,027 

979 

703 

116 

110 

105 

86 

75 

62 

72 

90 

62 

74 

53 

53 

41 

42 

49 

23 

35 

17 

14 

14 

'668 
549 
498 
456 
88 
78 
61 
69 
66 
75 
52 
53 
76 
77 
64 
37 
43 
34 
57 
45 

4o 
26 
26 

'585 
732 
573 
434 
79 
92 
61 
70 
96 
61 
37 
63 
50 
63 
73 
50 
52 
54 
49 
45 
25 
24 
15 
17 

i 

9 
9 

8 
1 
1 
6 
3 
2 
2 
1 
5 
5 
17 
9 

I 

7 
5 
4 
5 
6 
4 
5 

30 
45 
47 
66 

a 

7 
8 

10 
7 
8 
7 
5 
2 
3 
9 
3 
1 

12 
2 
2 
2 
1 
3 
1 

1.290 

1.335 

1.127 

964 

174 

178 

136 

152 

171 

146 

97 

126 

133 

160 

155 

91 

100 

107 

113 

96 

68 

76 

48 

49 

2.598 

1856-60  

1861-65  

1866-70  

1871-75  

1876 

2.221 
1.913 
1.765 
1.504 
1,446 

1877 

1.378 

1878 

1,347 

1379 

1.281 

1880 

1,185 

1881 

1,101 

1882 

1,076 

1883    

1,040 

1884 

969 

1885 

883' 

1886 

781 

1887 

743 

1888 

684 

1889 

619 

1890    

555 

1891 

482 

1892 

449 

1893 

390 

1894    

356 

1895 

321 

Total 

5,053 

3,279 

3.400 

126 

287 

7,092 

It  is  known  that  287  of  the  lepers  emigrated  from  Norway,  and 
of  these  about  170  went  to  North  America.  It  is  probable  that  the 
statistics  of  leper  immigrants  here  given  by  Hansen  are  very  much 
below  the  reality.  Hansen  believes  that  the  only  possible  explana- 
tion of  the  remarkable  decrease  in  Norway  is  that  the  segregation 
of  so  many  lepers  has  prevented  them  from  infecting  their  fellow- 
beings.  He  further  believes  that  the  most  effective  remedy  to  prevent 
the  spread  of  laprosy  is  the  isolation  of  as  many  as  possible  and  pre- 
venting them  from  infecting  others. 

Bussia. — Alarmed  by  the  obvious  increase  of  leprosy  in  Russia, 
the  Russian  Government  ordered  in  1895  a  general  census  of  leprosy 
in  its  dominions.  Twelve  hundred  and  ninety-nine  cases  were  re- 
ported, and  upon  examination  of  these  1,200  were  declared  lepers. 
In  1889  it  was  calculated  that  there  were  from  1,500  to  2,000  cases 
in  Russia,  and  that  the  number  was  increasing.  In  1877  Dr.  Walsh 
found  378  lepers  in  the  Baltic  province,  3  cases  at  Moscow  and  at  St. 


GEOGRAPHICAL  DISTEIBUTION.  661 

Petersburg.  In  South  Kussia,  tlie  Volga  districts,  tlie  Crimea,  the 
Don  Cossack  territory,  and  in  Turkestan  Professor  Munch  collected 
information  of  373  cases.  He  believes  that  the  Crimea  serves  as  the 
starting-point  for  leprosy  in  Southern  Kussia,  and  particularly  in  the 
Don  Cossack  territory.  Crimea  was  colonized  in  the  thirteenth  and 
fourteenth  centuries  by  the  Genoese,  who  brought  leprosy  with  them. 
In  some  settlements  the  number  of  lepers  is  from  1  to  300,  to  1 
to  1,000  of  the  population.  Such  centres  of  leprosy  have  interven- 
ing healthy  settlements  or  they  are  in  communication  with  each  other 
and  then  occupy  a  considerable  extent  of  territory  with  several  nests 
of  the  disease. 

South  America. 

The  western  coast  of  South  America  is  practically  free  from  lep- 
rosy. Middendorf  during  twenty-five  years'  practice  in  Peru  saw 
only  three  patients — two  Chinese  and  one  European. 

Upon  the  north  coast  the  disease  is  frequent  in  Venezuela  and  in 
Guiana.  In  Surinam  alone  there  are  from  five  hundred  to  two  thou- 
sand lepers. 

Leprosy  also  prevails  in  Curagoa,  St.  Martin,  and  St.  Eustatius. 

Leprosy  was  probaby  imported  into  Brazil  in  1644  by  the  Portu- 
guese. In  the  year  1697  there  were  so  many  lepers  in  Brazil  that  a 
special  hospital  was  asked  for  in  which  the  lepers  might  be  treated. 
During  the  last  two  centuries  it  has  spread  throughout  the  country. 
There  are  special  leper  hospitals  at  Pernambuco,  San  Paulo,  and  Eio 
de  Janeiro,  although  residence  is  not  compulsory  and  no  obligatory 
notification  of  the  disease  is  imposed  upon  physicians.  The  entire 
coast  of  Brazil  is  affected.  The  last  census  has  given  the  number  as 
five  thousand,  which,  according  to  Lutz,  does  not  indicate  one-half  of 
the  real  number. 

In  Uruguay,  Canabal  reports  that  there  are  only  twenty-seven 
lepers. 

The  disease  exists  likewise  in  the  Argentine  Repuhlic.  Since  1892 
there  has  been  noted  a  progressive  increase  in  the  number  of  lepers 
admitted  into  the  hospital  for  infectious  diseases  at  Buenos  Ayres. 
Gache  declares  that  the  disease  is  frequent  and  increasing  in  the  inte- 
rior of  the  country. 

British  Guiana. — Leprosy  was  introduced  into  British  Guiana  by 
blacks  from  Africa.  In  1831  the  government  report  showed  a  total 
of  431  lepers.  In  1841  there  were  65  lepers.  A  general  leper  asylum 
was  opened  at  Mahieia  in  1858.  During  twenty  years  from  1858  to 
1878  there  were  admitted  into  the  hospital  1,120  patients,  879  males 
and  223  females.     The  present  population  of  British  Guiana  is  278,- 


662  MORKOW— LEPROSY. 

000,  and  tlie  ratio  of  lepers  is  estimated  to  be  1  in  4,276.  According 
to  another  estimate  tliere  are  more  than  1,000  lepers  in  this  country. 

French  Gidaiia. — lu  this  country,  according  to  Laure,  one-tenth 
of  the  population  is  infected.  The  disease  was  imported  by  the 
blacks  from  South  Africa.  The  native  Indians  are  absolutely  exempt. 
At  Cayenne  the  number  of  lepers  is  between  100  and  120. 

Colombia. — The  first  authentic  case  of  leprosy  in  Colombia  was 
that  of  one  of  the  Spanish  governors  who  died  in  Bogota  in  1646. 
Leprosy  was  unknown  among  the  Indians  previous  to  that  period. 
The  disease  extended  slowly  during  the  next  two  hundred  years,  but 
in  the  last  two  or  three  decades  the  increase  has  been  very  rapid. 
Nearly  all  districts  where  leprosy  was  previously  unknown  have  been 
invaded,  and  now  nearly  every  locality  in  Colombia  is  more  or  less 
infected.  The  number  of  lepers  in  Colombia  is  not  positively  known. 
The  number  ioxij  years  ago  was  estimated  at  400 ;  at  present  it  has 
increased  to  27,000.  A  still  later  estimate  gives  the  number  at  not 
less  than  30,000.  In  the  three  hospitals  provided  for  the  reception 
of  lepers  there  were  in  1896  only  841  patients. 

The  West  Indies. 

Jamaica. — The  consensus  of  opinion  is  that  leprosy  was  brought 
to  the  West  Indies  by  negroes  imported  as  slaves  from  the  west  coast 
of  Africa.  The  first  ofiicial  recognition  of  the  disease  was  in  1865. 
In  1891  there  were  85  inmates  of  the  leper  home  in  Kingston.  The 
number  of  lepers  at  the  date  of  the  last  report  of  Dr.  Donovan,  was 
450,  or  1  in  1,555  of  the  total  population.  Donovan  thinks  that  many 
have  not  been  recognized. 

Trinidad. — The  government  census  returns  show  that  in  1871 
there  were  102  lepers,  93  per  1,000;  in  1881  there  were  149  lepers,  97 
per  1,000;  in  1891  there  were  225  lepers,  112  per  1,000.  These  re- 
turns are  not  accurate,  as  the  census  ordinance  made  no  provision 
for  obtaining  information  concerning  lepers  outside  the  leper  asy- 
lums. 

There  was  no  accurate  census  of  lepers  in  Trinidad  until  1889, 
although  the  number  was  variously  estimated  from  480  to  860.  The 
census  of  the  island  in  1889  showed  there  were  348  lepers,  210  of 
whom  were  in  the  asylum ;  43.56  per  cent,  were  coolies  who  had  the 
disease  when  they  arrived  from  India,  and  about  38  per  cent,  were 
natives  of  the  colony.  In  December,  1896,  there  were  218  inmates  of 
the  asylum.     The  disease  appears  to  be  on  the  increase. 

Leeivard  Islands. — The  census  of  1891  gives  the  total  number  of 
lepers  at  172. 


GEOGRAPHICAL  DISTRIBUTION.  663 

In  St.  Cliristopher  or  St.  Kitts  the  number  has  increased  from  72 
in  1872  to  120  in  1890. 

In  the  island  of  Antigua  there  were,  in  1891,  45  cases,  34  being 
in  the  asylum. 

In  both  islands  the  percentage  of  lepers  to  the  total  population 
has  doubled  in  the  last  twenty  years. 

French  Antilles. — Leprosy  is  extensively  spread  in  the  French 
Antilles.  At  Guadeloupe  and  Martinique  there  is  1  leper  to  every 
600  inhabitants.  According  to  M.  Brassac,  the  number  of  leper 
inmates  of  the  leproseries  of  the  two  colonies  on  the  island  of  Desi- 
rade  is  100. 

In  the  Danish  Antilles  there  are  at  least  22  at  St.  Thomas.  Santa 
Cruz  possesses  a  small  asylum  for  lepers,  but  entrance  is  not  compul- 
sory; they  go  and  come  as  they  please.  Their  present  number  is 
82,  36  men  and  46  women. 

In  Ciiba  and  Porio  Eico  the  disease  prevails  extensively.  There 
are  usually  about  80  lepers  in  the  San  Lazaro  Hosx)ital  of  Havana. 
There  are  other  hospitals  in  Santa  Clara  and  Puerto  Principe.  Con- 
finement in  none  of  these  hospitals  was,  under  Spanish  rule,  com- 
pulsory, nor  was  the  isolation  of  the  inmates  complete,  as  they  were 
always  allowed  to  go  out  during  certain  hours  without  any  restric- 
tions on  their  movements.  Under  American  rule  the  sanitary  author- 
ities of  Havana  have  ordered  the  sequestration  of  all  lepers  in  the 
city,  and  the  same  regulations  have  been  ordered  at  Santiago.  The 
total  number  in  Cuba  has  been  estimated  at  from  300  to  500,  which 
is  probabh"  below  the  reality. 

In  Porto  Eico  there  are  numerous  lepers,  but  there  are  no  statistics 
showing  the  actual  number. 

Barhadoes. — The  increase  of  leprosy  in  the  island  of  Barbadoes  is 
shown  by  the  census  of  1871,  96;  1881,  108;  1891,  156.  The  ratio  of 
the  increase  of  leprosy  to  the  increase  in  population  in  the  last  ten 
years  has  been  from  57  to  80  per  1,000.  There  were  114  cases  in  the 
lazaretto  at  the  last  report. 

St.  Vincent.— The  census  returns  of  1891  give  62  lepers,  an  increase 
of  only  5  since  1881.  In  the  asylum  there  were,  in  1894,  23  cases,  as 
against  19  in  1887. 

Santa  Lucia.— The  census  of  1891  gives  32  lepers.  In  Grenada 
in  1891  there  were  21  cases  according  to  the  census ;  in  the  census  of 
1881  there  were  only  3  cases. 

CEISfTEAIi  AjMERICA. 

There  are  no  authentic  statistics  of  leprosy  in  the  States  of  Cen- 
tral America.     Numbers  of  lepers  may  be  seen  in  Panama,  and  the 


664  MORROW — LEPROSY. 

disease  is  also  prevalent  iu  Costa  Rica,  Nicaragua,  Honduras,  Salva- 
dor, and  Guatemala.  In  the  latter  country  attempts  have  been  re- 
cently made  to  secure  segregation  of  the  infected. 

Mexico. 

There  is  every  reason  to  believe  that  leprosy  was  introduced  into 
Mexico  by  the  Spanish,  as  Cortez  established  a  lei:>er  hospital  in  the 
city  of  Mexico,  and  there  is  no  record  of  the  existence  of  leprosy  be- 
fore the  arrival  of  the  Spanish  conquerors.  The  states  of  Michacan 
and  Sinaloa  are  the  main  centres  of  leprosy.  The  states  of  Guanajuto 
and  Jalisco  and  tlie  adjacent  districts  of  the  adjoining  states  and  the 
state  of  Guerrora  iu  the  north  are  all  infected  with  lejDrosy. 

Orvaiianos  states  that  there  are  about  30  lepers  in  the  leper 
ward  of  the  Juarez  Hospital.  The  San  Pablo  serves  the  purpose  of  a 
general  hospital  and  a  hospital  for  typhus  fever  and  other  infectious 
diseases  and  also  as  a  leprosj'  hospital.  In  my  visit  to  the  hosjjital 
in  1889  I  found  11  cases  of  leprosy,  almost  all  of  them  of  the 
anaesthetic  type.  No  attempt  at  segregation  of  the  lepers  is  made  by 
the  authorities.  Many  lepers  may  be  seen  in  the  streets  of  the  city, 
and  their  entrance  to  the  hospital  is  voluntary  rather  than  compul- 
sory. The  special  leper  hospital  was  abolished  about  thirty-five  years 
ago.  Statistics  fail  to  show  whether  the  disease  has  been  on  the  in- 
crease or  not  since  the  discontinuance  of  any  attempt  to  isolate  lepers, 
but  many  Mexican  physicians  assert  that  the  disease  is  gradually 
decreasing. 

North  America. 

Owing  to  the  geographical  continuity  of  the  British  provinces  of 
North  America  with  the  United  States  and  the  intimate  intercourse 
between  the  inhabitants  of  the  two  contiguous  regions,  the  history  of 
the  introduction  and  spread  of  leprosy  in  the  United  States  and  Can- 
ada may  be  considered  together. 

New  Brunswick. — Little  is  known  as  to  the  origin  and  spread  in 
New  Brunswick.  Since  1815  it  has  existed  continuoush^  among  the 
French  settlements  near  the  Bay  of  Chaleurs  in  the  Gulf  of  St.  Law- 
rence. Leprosy  first  appeared  in  Tracadie,  situated  on  the  bank  of 
the  Gulf  of  St.  Lawrence,  at  the  mouth  of  Miramichi  Eiver.  It  was 
said  to  have  been  introduced  by  the  French  emigrants  from  St.  Malo, 
in  Normandy.  It  was  not  until  a  number  of  people  had  taken  the 
disease  that  public  attention  was  drawn  to  it,  and  a  lazaretto  on  Chel- 
dro  Island,  in  the  Miramichi  Eiver,  was  established  in  1844.  In  1849 
the  present  hospital  at  Tracadie  was  constructed  to  take  its  place. 
Altogether  alwut  150  cases  have  been  admitted  since  the  foundation 


GEOGRAPHICAL  DISTRIBUTION.  665 

of  the  hospital.  At  present  there  are  23  inmates.  The  laws  are  not 
sufficiently  stringent  to  compel  the  imprisonment  of  lepers  at  large, 
and  there  has  been  no  notable  increase  in  the  j'early  number  of 
inmates  in  a  long  period. 

Cape  Breton. — A  small  outbreak  of  leprosy  was  discovered  in  1892 
upon  the  Island  of  Cape  Breton.  There  were  then  11  cases  observed 
in  individuals  living  in  close  contact.  This  number  has  since  de- 
creased to  6  or  7  cases. 

British  Columbia. — About  ten  years  ago  the  existence  of  leprosy 
was  observed  among  the  Chinese  residents  of  the  British  Pacific 
coast.  In  1894  Dr.  Graham,  of  Toronto,  reported  7  cases,  6  of  which 
were  in  Chinamen  and  1  in  a  vv'hite  man.  The  patients  were  kept  in 
quarantine  on  an  island  near  the  City  of  Victoria. 

The   United  States. 

The  heterogeneous  character  of  the  population  of  the  United 
States,  embracing  representatives  of  so  many  of  the  nationalities 
of  the  old  world,  renders  it  probable  that  leprosy  has  been  intro- 
duced into  this  country  through  many  sources.  France,  Spain, 
Portugal,  Norway  and  Sweden,  Africa,  and  China,  as  well  as  Mexico 
and  South  America,  have  doubtless  furnished  contingents.  The  fact 
that  the  disease  shows  no  tendency  to  an  alarming  spread,  except 
on  our  Southern  seaboard,  notwithstanding  the  supply  of  infectious 
material  from  such  diverse  and  numerous  sources,  but  rather  shows 
a  tendency  to  die  out  with  the  death  of  the  imported  lepers,  would 
seem  to  indicate  that  the  soil  of  this  country  is  not  favorable  to  the 
geripination  and  growth  of  leprosy. 

The  importation  of  leprosy  in  the  United  States  may  be  traced  to 
several  distinct  sources. 

1.  It  was  introduced  into  the  Atlantic  coast  cities  and  the  coun- 
tries along  the  Atlantic  seaboard  from  the  West  Indies,  and  probably 
Africa  through  the  importation  of  slaves  and  intercourse  through 
travel  and  commerce  with  the  neighboring  West  India  islands. 

2.  By  leprous  immigrants  from  Norway  and  Sweden  into  the 
Scandinavian  colonies  of  Minnesota,  Wisconsin,  Iowa,  and  Dakota. 

3.  By  the  Acadian  refugees  from  the  British  provinces  of  New 
Brunswick  into  Louisiana. 

4.  By  lepers  from  Mexico  into  Texas  and  States  bordering  the 
Gulf  of  Mexico  and  the  Eio  Grande. 

5.  By  Chinese  immigrants  into  San  Francisco  and  elsewhere  on 
the  Pacific  coast. 

6.  By  Hawaiian  lepers  in  California,  Utah,  and  other  parts  of  the 
country. 


666  MORROW— LEPROSY. 

In  Boston,  New  York,  and  Pliiladelpliia,  and  other  large  cities 
there  has  always  been  a  variable  number  of  cases  of  leprosy,  made 
up  from  foreigners  of  the  various  countries  where  leprosy  is  endemic 
and  of  American  sailors,  soldiers,  and  civilians  who  have  visited  or 
resided  in  foreign  leprous  countries. 

In  New  Scandinavia,  embracing  certain  regions  in  the  Northwest- 
ern States  of  Minnesota,  Iowa,  and  Wisconsin,  whose  population  is 
estimated  to  be  over  one  million,  made  up  largely  of  immigrants  from 
Norway  and  Sweden,  have  been  observed  a  certain  numlier  of  lepers. 
Dr.  James  C.  White,  in  his  report  to  the  Berlin  Leprosy  Congress, 
1897,  estimates  that  there  were  168  leper  immigrants  who  either  had  the 
disease  when  they  left  home  or  in  whom  it  developed  after  they  came 
to  this  country  ;  of  these,  about  30  still  survive.  Investigations  which 
have  been  recently  made  would  seem  to  indicate  that  the  number  of 
Scandinavian  lepers  exceeds  the  figures  which  have  been  heretofore 
given.  It  is  probable  that  the  number  is  augmented  by  the  arrival 
of  new  cases  from  time  to  time  among  the  Norwegian  immigrants. 

Dr.  Bracken  says  we  have  knowledge  of  51  lepers  who  have  re- 
sided in  Minnesota,  of  whom  17  died  during  1890 ;  34  have  been  added 
to  the  records  since  1890,  29  from  Norway  and  5  from  Sweden.  The 
statistics  of  168  known  lepers  above  referred  to  could  not  have  in- 
cluded more  than  17  of  this  number  of  51. 

Dr.  Bracken  thinks  that  there  must  be  at  i:)re8ent  a  total  of  about 
20  lepers  in  Minnesota,  although  Northwestern  physicians,  who 
should  be  qualified  to  judge,  estimate  that  there  are  at  least  50.  He 
estimates  that  there  are  60  lepers  in  the  States  of  Wisconsin,  Iowa, 
North  and  South  Dakota,  and  128  in  other  parts  of  the  United  States, 
making  a  total  of  160  Scandinavian  lepers  in  the  United  States  at  the 
present  time.     Another  estimate  places  the  number  at  104. 

Utah. — In  1889  I  called  attention  to  the  fact  that  among  the  ac- 
cessions to  the  Mormon  population  of  Salt  Lake  City  there  has  been 
a  certain  number  of  lepers  among  the  Hawaiian  converts. 

Calif  or  ma.—HhQ  Chinese  population  of  our  Western  States  is 
quite  large — 25,000  in  San  Francisco  alone.  There  had  been  up  to 
1894,  as  estimated,  196  cases  of  the  disease  detected  in  the  State, 
most  of  which  have  been  reshipped  to  China  from  time  to  time. 
At  present  there  are  26  cases  of  the  disease  known  to  exist  in  Cali- 
fornia ;  a  number  are  confined  in  the  pest  house  in  San  Francisco. 
Among  the  inmates  of  the  pest  house  there  have  been  quite  a  number 
of  Hawaiian  lepers,  who  h.ave  come  to  this  country  either  for  treat- 
ment or  to  escape  the  rigorous  laws  of  sequestration  which  exist  there. 
Oregon. — In  this  State  a  number  of  cases  have  been  observed,  prin- 
cipally among  the  Chinese  residents. 


GEOGEAPHICAL   DISTRIBUTION.  667 

South  Carolina. — Turning  novs'  our  attention  to  the  Atlantic  sea- 
board, we  find  that  a  limited  focus  of  the  disease  was  reported  bv  Dr. 
Geddings  as  occurring  in  South  Carolina,  near  Charleston,  between 
1847  and  1882.  Sixteen  cases  have  been  observed  during  that  period; 
according  to  the  latest  reports  four  of  these  patients  still  survive. 

Florida.— The  proximity  of  Florida  to  the  infected  West  India 
islands  renders  the  importation  of  the  disease  extremelj^  easy.  Dur- 
ing the  last  ten  years  the  number  of  lepers  in  Florida  has  been 
variously  estimated  as  from  6  to  100. 

Texas. — I  have  had  personal  reports  of  three  cases  of  leprosy  in 
Galveston  and  a  number  in  San  Antonio.  Most  of  these  originated 
in  Mexico  or  in  Louisiana. 

Ohio. — Two  cases  have  been  reported  as  occurring  near  New  Lex- 
ington, Ohio.  The  opinion  of  medical  men  who  have  seen  them  is 
divided  as  to  whether  or  not  they  are  true  cases  of  leprosy. 

Louisiana. — The  most  important  centre  of  leprosy  in  the  North 
American  continent  is  in  Louisiana.  Leprosy  was  introduced  into 
this  State  by  the  Acadian  refugees  who  were  expelled  from  their 
homes  in  1758  and  who  settled  in  Lafourche  and  the  Tesche  Eiver 
districts,  and  it  is  also  claimed  that  it  was  introduced  into  New 
Orleans  from  Martinique.  It  increased  to  such  an  extent  that  a  hos- 
pital was  founded  in  New  Orleans  in  1785.  The  disease  gradually 
diminished,  and  the  hospital  decayed,  and  was  finallv  abandoned  in 
1807. 

No  definite  history  of  prevalent  leprosy  can  be  found  until  1866, 
although  that  leprosy  still  existed  during  this  period  is  evident  from 
the  records  of  the  admission  from  time  to  time  of  cases  in  the 
Charity  Hospital  of  New  Orleans.  The  attention  of  the  health 
authorities  was  not  attracted  to  its  increase  until  1866,  when  it  ap- 
peared in  Yermilion  Parish,  in  a  woman  whose  father  came  from 
Southern  France.  She  died  in  1870,  and  subsequently  four  children 
and  a  nejjhew  became  lepers.  From  this  centre  the  disease  has  spread 
through  several  other  districts  in  the  State  and  infects  both  native- 
born  citizens  and  the  alien  population.  Dr.  Jones  collected  a  total  of 
37  cases  from  1877  to  1880.  In  1889  Dr.  Solomon  reported  6  cases 
in  New  Orleans.  In  1883  Dr.  Blanc  reported  42  cases ;  in  1892  he  re- 
ported 41  additional  cases— 83  altogether. 

In  1894  Dr.  Dyer  reported  25  cases,  and  since  then  has  reported  91, 
a  total  of  116.  Most  of  the  cases  in  New  Orleans  originated,  according 
to  Dr.  Dyer,  in  the  district  near  where  the  old  leper  hospital  was 
situated.  A  lepers'  home  was  established  in  IlDerville  Parish  in  1895. 
Dr.  Dyer's  statistics  embrace  277  cases— 7  from  1800  to  1878;  270 
cases  from  1878  to  the  present  day.     Dr.  Dyer  reports  that  171  pa- 


668  MORROW— LEPROSY. 

tients  were  born  in  Louisiana,  8  elsewhere  in  the  United  States,  and 
39  were  born  in  Europe.  There  was  no  instance  of  heredity  and  no  pa- 
tients who  died  under  five  or  six  years.  One  hundred  and  thirty-one 
patients  are  supposed  or  known  to  be  living  at  the  present  time.  The 
regulations  for  the  compulsory  isolation  of  lepers  in  Louisiana  are 
not  stringently  enforced.  No  well-sustained  measures  for  the  control 
of  the  disease  have  been  adopted.  New  cases  are  continually  crop- 
ping up.  At  the  moment  of  this  present  writing  two  new  cases  have 
just  been  discovered  in  St.  John's  Parish,  both  natives  of  the  parish. 
Contagion  has  been  traced  to  their  association  many  years  ago  with 
an  old  leper  who  has  since  died  of  the  disease,  and  in  whose  cabin 
they  were  frequent  visitors. 

Hyde,  in  his  report  to  the  Congress  of  American  Physicians  and 
Surgeons  (1894)  upon  the  "  Distribution  of  Leprosy  in  North  Amer- 
ica," says :  "  It  may  thus  be  approximately  determined  that  the  cases 
of  leprosy  heretofore  recognized  in  the  United  States  have  been  dis- 
tributed as  follows :  In  Arkansas,  3 ;  in  California,  158 ;  in  Dakota, 
2 ;  in  Florida,  6 ;  in  Georgia,  1 ;  in  Idaho,  2 ;  in  Illinois,  13 ;  in  In- 
diana, 2 ;  in  Iowa,  20 ;  in  Louisiana,  83 ;  in  Maryland,  4 ;  in  Massa- 
chusetts, 5 ;  in  Minnesota,  120 ;  in  Missouri,  2 ;  in  Mississippi,  2 ; 
in  New  York,  100;  in  New  Jersey,  1;  in  Oregon,  3;  in  Pennsyl- 
vania, 6;  in  Utah,  3;  in  Wisconsin,  20— a  total  of  560."  It  is  evi- 
dent, however,  from  later  reports  that  the  number  of  lepers  in  this 
country  is  largely  in  excess  of  his  figures. 

Haivaii. 

The  position  of  the  Hawaiian  Islands  and  their  maritime  com- 
munication with  so  many  countries  where  leprosy  is  endemic  render 
possible  the  introduction  of  the  disease  from  numerous  sources. 
The  history  of  leprosy  in  the  Hawaiian  Islands  is  somewhat  vague. 
The  understanding  among  the  natives  is  that  it  was  introduced  by 
the  Chinese,  and  it  is  always  called  by  them  the  Chinese  disease, 
"  mai  paka."  The  first  case  came  to  notice  about  1848.  The  disease 
was  known  to  be  gradually  spreading  from  1855  to  1863,  but  the  at- 
tention of  the  health  authorities  was  not  awakened  to  the  alarming 
prevalence  of  the  disease  in  the  islands  until  1863  when  an  act  "  to 
prevent  the  spread  of  leprosy,"  which  provided  for  the  gathering 
together  of  all  the  lepers  of  the  kingdom,  with  a  view  to  their  isola- 
tion and  treatment,  was  passed.  In  1865  a  hospital  for  the  inspec- 
tion and  examination  of  lepers  was  built  at  Kalihi.  In  November, 
1864,  a  portion  of  the  island  of  Molokai  was  purchased  by  the  Gov- 
ernment.    Within  the  first  three  months  174  lepers  were  sent  to  the 


GEOGRAPHICAL  DISTRIBUTION. 


669 


settlement.  Since  its  establisliment  more  than  6,000  lepers  have  been 
consigned  to  the  settlement.  The  number  of  admissions  from  year  to 
year  varies  according  to  the  vigor  displayed  by  the  successive  health 
boards  in  carrying  out  the  provisions  of  law  for  the  detection,  arrest, 
and  isolation  of  the  lepers.  In  certain  years,  1873, 1883,  1888,  there 
was  a  notable  increase  in  the  number  of  lepers  sent  to  the  island,  the 
number  of  579  being  sent  in  the  latter  year  alone. 

.  The  following  table  which  has  been  carefully  compiled  from  the 
reports  of  the  Hawaiian  Board  of  Health  shows  the  number  of  admis- 
sions, the  mortalitj^  and  the  number  on  the  books  at  the  end  of  each 
year  from  the  establishment  of  the  settlement  to  January  1st,  1898. 


Year. 

.  o 
•a  .2 

s 

XD 

IS    1  o 

«  8 

Year. 

10 

s 

•-A 
1  ' 

P 

1.5 

1864* 

141 

26 

10 

105 

1888 

71 

131 

6 

649 

1867 

70 

25 

7 

143 

1883 

801 

150 

15 

785 

1868 

115 

28 

2 

338 

1884 

108 

168 

8 

717 

1869 

126 

59 

11 

384 

1885 

103 

143 

36 

655 

1870 

57 

58 

4 

379 

1886 

43 

100 

8 

590 

1871 

183 

51 

9 

403 

1887. ....... 

330 

108 

4 

698 

1873 

105 

64 

4 

439 

1888 

579 

312 

28 

1,085 

1873 

487 

156 

31 

749 

1889 

308 

149 

7 

1,187 

1874 

91 

161 

8 

671 

1890 

303 

158 

18 

1,313 

1875 

213 

163 

14 

706 

1891 

143 

313 

2 

1,143 

1876 

96 

123 

8 

677 

1893 

109 

137 

19 

1,095 

1877 

168 

139 

1 

710 

1893 

311 

151 

1,155 

1878 

239 

147 

803 

1894 

138 

155 

3 

1,134 

1879 

135 

209 

1 

717 

1895 

106 

138 

15 

1,087 

1880 

51 

153 

10 

606 

1896 

146 

116 

2 

1,115 

1881 

233 

133 

706 

1897 

134 

139 

1,100 

*  Settlement  opened. 

It  will  be  seen  from  the  above  table  that  in  the  first  twenty  years 
of  its  establishment,  to  January  1st,  1866,  there  were  3,036  lepers  ad- 
mitted ;  in  the  next  ten  years,  2,049.  In  the  first-mentioned  period  the 
number  of  lepers  was  from  200  to  800,  the  average  being  about  500.  In 
recent  years  the  number  has  varied  from  1,000  to  1,200.  This  large 
excess  is  explained  by  the  health  authorities  by  the  fact  that  they  are 
now  sent  there  at  early  stages  of  the  disease.  The  average  death  rate 
of  the  lepers  has  been  reduced  from  20  to  25  per  cent,  to  13  to  15 
per  cent.  Leprosy  is  by  no  means  confined  to  the  native  i)opulation. 
In  the  first  twenty  years  of  the  leper  settlement,  among  the  3,036  ad- 
missions there  were  22  Chinamen  and  16  whites,  about  1  per  cent. 
With  the  past  ten  years  the  number  of  foreigners  has  averaged  from 
3  to  5  per  cent. 

The  Chinese  furnish  the  largest  contingent  of  the  foreign  popu- 


670  MORROW— LEPROSY. 

lation  of  the  settlement.  Among  the  nationalities  represented  are 
Americans,  British,  Germans,  Portuguese,  Spanish,  Russians,  ne- 
groes. South  Sea  Islanders,  etc.  It  has  always  been  the  policy  of 
the  board  to  return  to  their  own  countries  when  possible  the  Chi- 
nese and  Jaj)anese  laborers  who  become  lepers.  More  than  100  cases 
of  leprosy  have  occurred  among  the  white  population  which  are 
not  included  among  the  statistics  of  the  leper  settlement.  Man}-  for- 
eigners learn  the  nature  of  their  disease  from  their  own  physicians 
and  voluntarily  return  to  this  country  or  Euroi^e  for  treatment.  The 
endemic  of  leprosy  in  Hawaii  has  afforded  an  excellent  opportunity 
of  studying  the  disease  by  competent  medical  men,  enabling  them  to 
trace  its  origin  and  the  influences  of  heredit}^  contagion,  racial  and 
other  characteristics,  food,  climate,  modes  of  life,  etc.,  in  favoring 
its  spread. 

In  studying  the  geographical  distribiition  of  leprosy  an  attempt 
has  been  made  to  give  the  statistics  of  the  disease  in  various  countries, 
which  have  been  compiled  from  the  most  reliable  data  accessible,  and 
also  the  indications  which  point  to  an  increase  or  decrease  of  the  dis- 
ease. It  is  to  be  understood,  however,  that  these  statistics  are  apt  to 
be  misleading,  as  indicating  a  number  which  falls  far  below  the 
reality. 

As  regards  the  actual  percentage  of  lepers  in  various  countries, 
it  is  for  obvious  reasons  an  unknown  and  unknowable  quantity.  Any 
one  familiar  with  the  natural  history  of  leprosy  must  recognize  that 
it  is  impossible  to  compute  the  number  of  lepers  in  any  country  by 
the  methods  ordinarily  used  for  the  detection  and  registration  of  dis- 
ease; only  advanced  cases  are  recognized  by  inspection.  In  every 
country  where  leprosy  is  endemic  a  large  number  of  persons  are  in- 
fected months  and  years  before  it  is  known  to  themselves  or  to  others. 
The  disease  exists  in  a  latent  state,  but  it  is  none  the  less  leprosy. 

Many  of  the  above  statistics  are  based  upon  the  number  of  lepers 
in  the  hospitals  or  asylums  provided  by  the  government  or  health 
authorities.  Only  a  small  proportion  of  the  leper  community,  and 
those  probably  paupers  or  advanced  cases,  enter  these  institutions. 
In  many'  countries  official  cognizance  is  not  taken  of  leprosy  until  the 
patients  reach  an  advanced  stage  of  the  disease.  In  the  government 
enactments  for  the  control  and  suppression  of  leprosy  in  the  various 
British  colonies,  the  ordinance  relating  to  leprosy  thus  defines  the 
disease :  "  A  leper  means  any  person  suffering  from  any  variety  of 
leprosy,  in  whom  the  in'ocess  of  ulceration  has  commenced."  Again, 
"the  term  '  infectious  lepros}-,'  is  to  be  interpreted  as  meaning  one 
who  has  leprosy  in  an  advanced  and  grievous  stage."     Only  pauper 


GEOGEAPHICAL  DISTRIBUTION.  671 

lepers,  unable  to  provide  for  themselves,  come  under  governmental 
supervision.  It  is  evident  that  in  all  these  countries  a  large  propor- 
tion of  lepers,  unless  the  disease  is  advanced  and  presumably  infec- 
tious, do  not  come  within  the  category  of  cases  subject  to  segregation 
in  hospitals  or  asylums. 

The  leper  settlements  are  not  a  popular  institution  in  any  country, 
and  a  leper  is  not  apt  to  jiresent  himself  when  he  knows  that  his  con- 
finement is  virtually  a  lifelong  imi)risonment.  As  a  consequence,  in 
countries  where  a  strict  policy  of  segregation  is  adopted  lepers  use 
every  possible  precaution  to  conceal  all  incriminating  evidence  of  the 
disease,  and  when  concealment  is  no  longer  possible  they  are  often 
secreted  and  cared  for  by  their  relatives  and  friends.  Again,  the 
very  severity  of  the  measures  necessitated  by  a  rigorous  policy  of 
segregation  is  indirectly  a  cause  of  its  partial  failure.  -  The  severity 
of  the  banishment  stimulates  all  the  inventive  resources  of  the  patient 
to  elude  arrest.  It  is  a  matter  of  general  knowledge  that  in  Hawaii, 
where  segregation  is  rigorously  enforced,  lepers  hide  themselves  or 
are  secreted  by  their  friends,  or  they  flee  to  the  mountains  and  forests 
for  concealment. 

Another  source  of  error  arises  from  the  difficulties  which  attend 
the  diagnosis  of  the  disease  and  applies  with  special  emphasis  to 
most  countries  where  leprosy  prevails  to  the  greatest  extent.  In 
countries  such  as  Europe  and  the  United  States  and  in  the  modern 
leprosy  centres  of  Norway  and  Hawaii  it  would  appear  practicable  to 
give  facts  and  figures  with  approximative  certainty  and  also  to  arrive 
at  conclusions  respecting  the  progressive,  stationary,  or  retrogressive 
character  of  the  disease  which  have  a  definite  scientific  value.  This 
is  obviously  not  the  case  in  semi-civilized  and  Oriental  countries, 
which  are  not  under  skilled  medical  surveillance.  In  many  Oriental 
countries,  such  as  Northern  China,  Japan,  Thibet,  the  hill  countries 
of  India,  and  also  Africa,  we  are  compelled  to  rely  largely  upon  the 
testimony  or  reports  of  native  doctors,  travellers,  missionaries,  and 
others  who  are  unfamiliar  with  the  characteristics  of  leprosy  and  who 
in  most  instances  would  be  unable  to  recognize  the  disease  when  they 
saw  it. 

According  to  Dr.  Murata,  of  the  Investigation  Bureau  of  Conta- 
gious Diseases  (Tokio) ,  quoted  by  Ashmead,  the  statistics  of  the  Jap- 
anese Health  Department  give  the  total  number  of  lepers  in  Japan  at 
23,660,  but  in  Dr.  Murata's  opinion  this  figure  could  be  doubled  or 
trebled  without  exaggeration. 

The  inability  to  diagnose  leprosy  applies  to  many  medical  men, 
who  may  come  in  contact  with  the  disease  without  knowing  it,  espe- 
cially the  anaesthetic  form.     Even  in  countries  advanced  in  civiliza- 


672  MORROW — LEPROSY. 

tion  it  is  practically  impossible  to  get  accurate  figures.  Leprosy  is 
uot  recognized  on  ordinary  inspection  except  when  the  disease  is 
advanced  in  its  evolution  and  more  or  less  disfiguring.  There  are 
many  cases  which  are  suspicious  and  not  well  defined,  so  that  even 
skilled  leprologists  may  hesitate  or  find  it  impossible  to  pronounce  a 
positive  diagnosis. 

Norway-  and  Hawaii  have  been  instanced  as  countries  in  which  it 
would  .seem  possible  to  arrive  at  an  ai)j)roximately  correct  estimate  of 
the  number  of  cases  of  leprosy,  since  they  are  directly  under  skilled 
sanitary  supervision. 

In  Norwaj^  the  official  count  of  the  number  of  lepers  in  1856  was 
given  as  2,221.  It  has  since  transpired  that  the  actual  number  at 
that  date,  verified  b3'  the  deaths  taken  from  the  Bureau  of  Yital  Sta- 
tistics, was  nearly  one  thousand  more  than  was  calculated. 

Again,  the  statistics  of  leprosy  in  Hawaii  are  also  to  a  certain 
extent  misleading,  although  the  method  adopted  by  the  sanitarj^  au- 
thorities is  systematic  and  well  organized.  There  are  about  twenty 
government  physicians  established  in  the  different  districts  of  the 
various  islands,  one  of  whose  important  duties  is  to  report  all  sus- 
pected cases  of  leprosy,  and  the  police  officers  are  empowered  to 
bring  every  suspected  leper  to  the  Kalahi  reception  hospital  for  ex- 
amination, and  all  i)ersons  who  are  pronounced  lepers  are  forwarded 
by  the  next  boat  to  the  leper  settlement  to  remain  there  until  they  die. 
The  number  consigned  each  year  depends  upon  the  more  or  less  vig- 
orous policy  of  the  Board  of  Health  and  the  activity  of  the  agents 
of  the  board  in  identifying  and  ajiprehendiug  the  lepers. 

In  the  report  of  the  Hawaiian  Board  of  Health  (1890),  we  read 
(page  13) :  "  According  to  the  best  information  obtainable  there  are  at 
the  date  of  this  rejKjrt  about  one  hundred  persons  supposed  to  be 
affected  by  the  disease  still  at  large  who  have  not  been  before  the 
examining  board,"  and  yet  the  statistics  of  the  leper  settlement  dur- 
ing the  next  eight  j-ears  shows  that  there  were  twelve  hundred  lepers 
sent  to  the  leper  settlement,  or  within  the  first  five  years  seven  hun- 
dred and  ninety-three  admissions.  Now  leprosy  does  not  develop 
tVemhlee;  it  may  preserve  its  incognito  for  five  or  ten  jears,  or  even 
longer,  before  its  identity  is  declared.  It  is  probable  that  most  of 
these  twelve  hundred  persons  sent  to  the  settlement  and  manj-  more 
not  apprehended  were  lepers  on  March  31st,  1890,  when  the  Board 
of  Health  reports  that  there  were  only  about  one  hundred  lejoers  at 
large. 

One  element  to  be  considered  in  the  calculation  of  the  number  of 
lepers  is  the  vast  number  of  cases  of  incipient,  latent,  or  undeveloped 
leprosy  existing  in  all  countries  where  leprosy  is  endemic.     These 


BIBLIOGRAPHY.  673 

cases  may  not  be  detected  in  the  earlier  stages,  but  they  are  none  the 
less  leprosy,  and  as  the  disease  develops  into  a  recognizable  form 
they  furnish  recruits  to  the  ranks  of  the  leper  population. 

From  these  and  other  facts  we  must  conclude  that  all  statistics  of 
leprosy  in  different  countries  are  inexact,  as  they  indicate  a  much 
lower  number  than  actually  exists.  In  the  writer's  opinion  the  figures 
should  be  doubled  or  trebled  in  order  to  arrive  at  the  actual  number 
of  cases.  In  the  same  way  the  number  of  cases  of  leprosy  in  different 
cities,  such  as  New  York,  Boston,  Philadelphia,  is  largely  underesti- 
mated. The  writer  has  personally  seen  over  fifty  cases  of  leprosy  in 
New  York,  without  taking  into  account  the  number  coming  under  the 
observation  of  other  specialists. 


Bibliography. 

Abbott,  S.  W.  :   Leprosy  as  related  to  Public  Health.     Report  of  the  Massa- 
chusetts Board  of  Health,  Boston,  1883. 

Abraham,  Phineas  S.  :  Leprosj' ;  a  Review  of  Some  Facts  and  Figures.     Glas- 
gow Medical  Journal,  1890. 

The  Etiology  of  Leprosy  ;  a  Criticism  of  Some  Current  Views.     Jour- 
nal of  the  American  Medical  Association,  1889. 

On  a   Supposed    Case  of    Indigenous  Leprosy    (really   Carcinoma) . 

Transactions  of  the  Pathological  Society  of  London,  1891. 

An  Analysis  of  One  Himdred  and  Eighteen  Cases  of  Leprosy  in  the 

Tartaran  Asylum  (Punjab)  ;  and  on  the  Arrest  and  Cure  of  Leprosy  by  the  Ex- 
ternal and  Internal  Use  of  the  Gurjun  and  Chaulmoogra  Oils,  by  the  Hon.  J.  C. 
Phillippo,  M.D.  Reprint  of  a  Communication  to  the  Epidemiological  Society  of 
London,  1890. 

Alibert :  Article  L^pre  in  Traite  des  Maladies  de  la  Peau,  1825. 

Allen :  Tuberculin   in   Leprosy.      Journal  of  Cutaneous  and    Genito-Urinary 
Diseases,  1891. 

'■ —  Leprosy  in  the  United  States  and  its  Relation  to  the  State.     Medical 

and  Surgical  Reporter,  1888. 

Anderson,  A.  F.  ;  Colored  Portraits  of  Leprosy  as  met  with  in  the  Straits  Set- 
tlements, London,  1872. 

Anticosti,  Leprosy  in.     New  York  Herald,  July  14,  1890. 

Aretseus  Cappadox  ;  De  causis  et  signis  morborum,  lib.  iii. 

Arning,  Edward  :  Copies  of  Report  of  Dr.  Edward  Arning  to  the  Hawaiian 
Board  of  Health  and  of  the  Correspondence  Arising  Therefrom,  Honolulu,  1886. 

—Leprosy;  Its  Spread  by  Hereditary  Transmission  or  by  Contagion. 

Archiv  fiir  Dermatologie  und  Syphilis,  1891. 

Mittheilungen    iiber    Versuche  mit  der  Koch'schen  Infectionsfliis- 

sigkeit  bei  Lepra  und  Lupus  Erythematodes.  Deutsche  medicinische  Wochen- 
schrift,  1890. 

Ashmead,  Albert  S.  :  Tuberculosis  and  Leprosy  in  Japan  ;  a  Study  in  Ethno- 
logical Pathology.     Journal  of  the  American  Medical  Association,  1891. 

Immunity  from  Leprosy   of   the  Fifth   Generation.      International 

Medical  Magazine,  Philadelphia,  1892. 
Vol.  XVHL— 43 


674  MORROW— LEPROSY. 

Pre-Columbian  Leprosy.  Journal  of  the  American  ]\Iedical  Associa- 
tion, 1895. 

Suppression  and  Prevention  of  Leprosy,  Norristown,  Pa.,  1897. 

The  Church  of  Rome  and  the  Lepers  of  Columbia.     Journal  of  the 

American  Medical  Association,  1896. 

Our  Danger  of  Leprosy  from  Japan.     Medical  Standard,  1899. 

The  jlosquito  and  Leprosy.     Medical  Herald,  1898. 

Atiiinson,  J.  E.  :  A  Case  of  Tubercular  Leprosy  Originating  in  Contagion. 
Transactions  of  the  American  Dermatological  Association,  1881. 

Babcock,  J.  L.  :  A  Case  of  Lepra  Nervorum.     Medical  Record,  1888. 

Barduzzi,  D.  :  Sulla  etiologia  parassitaria  della  lebbra.  Giornale  Italiano 
delle  Malattie  Venereali,  1883. 

Baude,  E.  :  A  propos  d'un  Cas  de  Lepre  Observe  a  Lille.  Annales  de  Derma- 
tologie  et  de  Syphiligraphie. 

Baum,  W.  L.  :  Leprosy  and  Vaccination.     Medical  Standard,  1893. 

Baumgarten  :  Ueber  die  Farbungsunterschiede  zwischen  Lepra-  und  Tuberkel- 
bacillen.     Centralblatt  fiir  Bakteriologie  und  Parasitenkunde,  1890. 

Bazin :  Le9ons  sur  les  affections  cutanees  artificielles  et  sur  la  lepre,  Paris, 
1862. 

B.  E.  :  Leprosy  in  Madagascar.     Illustrated  Medical  News,  1889. 

Beltleld,  W.  S.  :  The  Bacillus  of  Leprosy.  Journal  of  Cutaneous  and  Venereal 
Diseases,  1882. 

Benson,  J.  H.  :  Dublin  Journal  of  Medical  Science,  1877. 

Berge,  Phillippe ;  Chaulmoogra  Oil  in  the  Treatment  of  Leprosy.  New 
Orleans  Medical  and  Surgical  Journal,  1891. 

Bergmann,  A.  :  Ueber  Lepra  in  Riga.  St.  Petersburger  medicinische  Wochen- 
schrift,  1885. 

Bermann,  I.  ;  The  Bacillus  Leprae.     Archives  of  Medicine,  1882. 

Bernhard,  Gordon  (Montpelier,  1303)  :  Librum  Medicinsxi  Inscriptum,  etc. 
Opera  Medica,  1571. 

Bertrand,  J.  H.  :  Report  of  a  Case  of  Leprosy.  Medical  and  Surgical  Reporter, 
1891. 

Besnier,  Ernest :  Sur  la  Lepre,  Nature,  Origine,  Transmissibilite,  Modes  de 
Propagation  et  de  Transmission.  Bulletin  de  I'Academie  de  Medecine  de  Paris, 
1887. 

Bidenkap,  T.  L.  :  An  Abstract  of  Lectures  on  Lepra,  London,  

Blakewell,  O.  H.  :  Report  on  Dr.  Beauperthuy's  Treatment  of  Leprosy,  1871. 

Blanc,  H.  W.  :  Leprosy  in  Louisiana  ;  Necessity  of  Providing  for  Lepers. 
New  Orleans  Medical  and  Surgical  Journal,  1890. 

Leprosy  in  New  Orleans.  New  Orleans  Medical  and  Surgical  Jour- 
nal, 1888-89. 

The  Leprosy  Question.  Journal  of  the  American  Medical  Associa- 
tion, 1892. 

Boinet  .  Etudes  medicales  ;  recherches  experimentales  et  bacteriologiques  faites 
a  Tonquin,  1887-88.     Journal  d' Hygiene  de  Paris,  1889. 

Boinet,  E.  et  Borrel,  A.  :  De  la  cellule  geante  dans  la  ISpre.  Revue  de  Mede- 
cine, 1891. 

Bordoni-Uffreduzzi,  G.  :  Ueber  die  Cultur  des  Leprabacillus.  Zeitschrift  fiir 
Hygiene,  1887. 

Notiz  'iber  Leprabacillus.     Zeitschrift  fiir  die  medicinlschen  Wissen- 

Echaften,  1888. 


BIBLIOGRAPHT.  675 

•  Zur  Frage  des  Leprabacillus.     Berliner  klinische  Wochenschrift,  1888. 

Brocq,  L.  :  La  Lepre,  doit-elle  etre  consideree  comme  une  Affection  Conta- 
gieuse?    Annales  de  Dermatologie  et  de  Syphiligraphie,  1887. 

Brousse,  A.  :  Sur  un  cas  de  lepre  tuberculeuse  ;  amelioration  rapide  par  I'huile 
de  chaulmoogra.  Gazette  hebdomadaire  de  la  Societe  Medicale  de  Montpelier, 
1890. 

Brown,  A.  M.  :  Some  Comments  on  Leprosy  in  its  Contagio-Syphilitic  and 
Vaccinal  Aspects,  London. 

Bruns,  H.  D.  :  A  Clinical  Study  of  Leprosy.     Archives  of  Medicine,  1881. 

Bulkley,  L.  D.  :  The  Non-Contagiousness  of  Leprosy.     Medical  Record,  1892. 

Bull  and  Hansen  :  The  Leprous  Diseases  of  the  Eye,  London,  1874. 

Calhoun,  C.  W.  :  A  Study  of  Leprosy  at  Mount  Lebanon,  Syria.  Medical 
Record,  1883. 

Campana,  R.  :  Note  clinlche  ed  anatomiche  sulla  lepra,  Milan,  1881. 

Un  segno  semiologico  nella  lepra  tubercolare  incipiente,  Milan,  1883. 

Delia  trasmissibilita  della  lepra  negli  animali  Lruti   saluti.      Italia 

medica  di  Genova,  1883. 

Alcune    inoculazioni    di    noduli    leprosi.     Archivio  per    le  scienze 

mediche,  1883-84. 

Tentari  ripetuti,  ma  senza  risultato  positivo  nella  cultura  del  baclllo 

leproso.     La  Riforma  medica,  1889. 

Cantlie  :  Leprosy  in  Hong-kong,  1890. 

Leprosy  in  China,  Indo-China,  etc. ,  London,  1897. 

Carnochan,  J.  M.  :  Case  of  Elephantiasis  Graecorum  Treated  by  Ligature  of 
the  Common  Carotid  Artery  on  Both  Sides.  American  Journal  of  the  Medical 
Sciences,  1867. 

Carrasquilla,  L.  J.  ;  Disertacion  sobre  la  etiologia  y  el  contagio  de  la  lepra. 
Revista  medica  de  Bogota,  1889-90. 

Serotherapie  de  la  Lepre.     Transactions  of  the  National  Academy  of 

Medicine,  Bogota,  1899. 

Carter,  H.  V.  :  Transactions  of  the  Medical  and  Physical  Society  of  Bombay, 
1862. 

Leprous  Nerve  Disease.     Pathological  Society  Transactions,  1876-77. 

Leprosy  and  Elephantiasis,  1874. 

. The  Lymphatics  in  Leprosy.     The  Lancet,  1879. 

Cavasse,  Jacques;  Contribution  h  1' etude  de  la  ISpre  aux  Antilles  et  dans  le 
Levant,  Paris,  1881. 

Chapin,  Henry  Dwight :  Experiments  upon  Leprosy  with  the  Toxins  of  Ery- 
sipelas.    Medical  Record,  January  7,  1899. 

Charcot :  LSpre  anesthesique.     Le  Progr^s  medical,  1880. 

Charza  :  Leprosy  in  Ancient  India,  1889. 

Chauliac,  Guy  de  (Avignon,  1363)  :  Chirurgia  magna,  1585. 

Cornil :  Sur  le  siege  des  bacteries  dans  la  l^pre,  et  sur  les  lesions  des  organes 
dans  cette  maladie.     Union  medicale,  1881. 

Cottle  :  Chaulmoogra  Oil  in  Leprosy.     British  Medical  Journal,  1879. 

Cremer,  C.  L.  :  Lepra  in  Brasilien.     Deutsche  Medicinalzeitung,  1890. 

Damaschino:  Documents  pour  servir  a  I'etude  anatomo-pathologique  de  la 
Igpre.     Archives  de  Medecine  et  d'Anatomie  pathologique,  1891. 

Damien,  J.  :  Personal  Experience  of  Thirteen  Years'  Residence  and  Labor 
among  the  Lepers  at  Kalawao.     Report  of  the  Hawaiian  Board  of  Health,  1886. 

Damsch  :  Virchow's  Archiv,  1883. 


676  MORKOW— LEPROSY. 

Daniellsen  et  Boeck :  Traite  de  la  spedalskhed  ou   elephantiasis  des  grecs. 

Daubler :  Ueber  Lepra  und  deren  Contagiositat.  Monatshefte  filr  praktische 
Dermatologie,  1889. 

Dehio :  Ueber  die  Erkrankung  der  peripheren  Nerven  bei  der  Lepra.  St. 
Petersburger  niedicinische  TVocbenschrift,  1889. 

Dock,  G.  :  Leprosy,  Tvith  a  Report  of  Two  Cases.  Transactions  of  the  Texas 
Medical  Association,  1889. 

Dougall :  Gurjun-Oil  Treatment  of  Leprosy  in  Different  Countries.  Report  of 
the  Hawaiian  Board  of  Health,  1886. 

Downes,  E.  :  On  Nerve  Stretching  for  Leprosy  in  Kashmir.     The  Lancet,  1886. 

Doyon  et  Diday  :  Comment  devient  ou  lepreux?     Lyon  medical,  1888. 

Drognat-Laudre,  C.  L.  :  De  la  contagion  de  la  l^pre,  Paris,  1869. 

V.  During:  La  contagiosity  de  la  ISpre.     Gazette  medicale  de  1 'Orient,  1890. 

Durodie  .  Etude  sur  la  li^pre  tuberculeuse  et  les  leprosieries  fondees  a  Bordeaux 
et  en  Gugenne  au  moyen  age.  Bulletin  de  la  Societe  de  Medecine  et  de  Chirurgie 
de  Bordeaux,  1888-84. 

Dyer,  I.  ;  Leprosy.     Texas  Medical  Journal,  1894. 

■ — -  Report  ou  the  Leprosy  Question.     Reprinted  from  tlie  Proceedings  of 

the  Orleans  Parish  Medical  Society.  1894. 

Endemic  Leprosy  in  Louisiana.     Philadelphia  Medical  Journal,  1898. 

First  Annual  Report  of  the  Louisiana  Leper  Home,  New  Orleans, 

1898. 

Ehlers,  Edward  :  Conditions  under  which  Leprosy  has  Declined  in  Iceland, 
London,  1895. 

Leprosieries  Danoises  du  moyen  age.     Janiis,  1899. 

La  Distribution  Geographique  de  la  Lepre.     Janus.  1888-89. 

Emerson,  N.  B.  :  Report  on  the  Leper  Settlement  at  Kalawao,  1880. 

Etienne,  Pierre  O.  P.  :  La  lepre  est  contagieuse,  Paris,  1879. 

Fagerlund,  L.  W.  .  A  Leper  Colony  in  Finland.  American  Practitioner  and 
News,  1891. 

Farquharson,  R.  J.  :  Leprosy  in  the  United  States.     The  Sanitarian,  1894. 

Fitch,  G.  L.  :  Report  on  Leprosy  in  Hawaii.  1886. 

Fleming,  J.  N.  ,  Notes  on  the  Carbolic  Treatment  of  Leprosy.  India  Medical 
Gazette,  1871. 

Ford,  William  H.  :  On  the  Necessity  of  Founding  a  Leper  Colony  in  the  United 
States.     Medical  and  Surgical  Reporter,  1890. 

Forne  :  Contagion  dans  la  L6pre.     Le  Progr^s  medical,  1891. 

Fox,  G.  H.  :  A  Case  of  Leprosy  Apparently  Cured.  New  York  Medical  Jour- 
nal, 1890. 

Remarks  on  the  Treatment  of  Leprosy.      Quarterly  Bulletin  of  the 

Clinical  Society  of  the  New  York  Post-Graduate  Medical  School,  1885-86. 

Fox,  Tilbury  :  Leprosy,  Ancient  and  Modern,  Edinburgh,  1886. 

Fox,  Tilbury,  and  Farquhar :  On  Certain  Endemic  Skin  and  Other  Diseases  of 
India  and  Hot  Climates,  London,  1875. 

Foy,  G.  •  Therapeutic  Value  of  Gurjuu  Oil  in  Leprosy.  Medical  Press  and 
Circular,  1889. 

Gairdner,  W.  T.  :  A  Remarkable  Experience  Concerning  Leprosy,  Involving 
Certain  Facts  and  Statements  Bearing  on  the  Question,  Is  Leprosy  Communicable 
through  Vaccination?    British  Medical  Journal,  1887. 

Galen  :  De  causis  morborum  ;  de  tumoribus. 

Garcia,  C.  :    Topografia  del  Mai  de  San  Lazaro  en  la  Republica  Mexicana,  y 


BIBLIOGRAPHY.  677 

estudio  sobre  sus  causas  j  una  planta  dei  pais  con  que  se  cura.     Estudio  Mexico, 
1875-76. 

Gardner,  C.  W.  :  Leprosy  in  Japan  and  its  Treatment  with  Copaiba.  Medical 
Record,  1889. 

Gaston,  J.  McF.  :  Leprosy  as  Seen  in  Brazil.  New  Orleans  Medical  and  Sur- 
gicalJournal,  1883-84. 

Gaucher,  E.,  et  Hillairet ;  Parasitisme  de  la  ISpre.     Le  ProgrSs  medical,  1880. 

Cultures  des  bact^ries  de  la  ISpre.     Comptes  rendus  de  la  Societe  de 

Biologic,  Paris,  1883. 

Geddings  :  A  Case  of  Indigenous  Leprosy.     Medical  Record,  1884. 

The  Simultaneous  Occurrence  of  Three  Cases  of  Lepra  in  One  Family ; 

a  Contribution  to  the  History  of  Leprosy  on  the  Eastern  Coast  of  the  United  States. 
Climatologist,  ii.,  1893. 

Gianturco  :  Ricerche  istologiche  e  bacteriologiche  sulla  lepra.  Giornale  della 
Associazione  Napoletana  di  Medici  e  Naturalisti,  1890. 

Glorget :  La  Contagiosite  de  la  L^pre.  Th^se  de  Montpellier.  Journal  des 
Maladies  Cutanees  et  Syphilitiques,  1889. 

Goldschmidt:  Behandlung  der  Lepra  mit  der  Koch'schen  Lymphe.  Berliner 
klinische  Wochenschrift,  1891. 

Die  Lepra  auf  Madeira.     Berliner  klinische  Wochenschrift,  1881. 

Gomez  :  Leprosy  in  Mexico.     Report  of  the  Hawaiian  Board  of  Health,  1886. 

Goto,  M.  :  Report  on  the  Goto  Method  of  Treatment,  in  the  Report  of  the  Ha- 
waiian Board  of  Health,  1886. 

Graham,  J.  E.  :  Leprosy  in  New  Brunswick.  Canadian  Medical  and  Surgical 
Journal,  1883-84. 

Gronwold,  C.  :  Notes  on  Cases  of  Leprosy  in  Minnesota.  Archives  of  Derma- 
tology, 1879. 

Leprosy  in  Minnesota.     Journal  of  Cutaneous  and  Venereal  Diseases, 

1884. 

Guttmann,  P.  :  Ueber  Leprabacillen.     Berliner  klinische  Wochenschrift,  1885. 

Hagan,  M.  :  Leprosy  on  the  Hawaiian  Islands.  Southern  California  Practi- 
tioner, 1886. 

Hansen,  G.  A.  :  Explanation  of  the  Causes  which  have  Led  to  the  Disease  of 
Leprosy  in  Norway.     St.  Paul  Medical  Journal,  1899. 

The  Bacillus  of  Leprosy.     Quarterly  Journal   of  the  Microscopical 

Society  of  London,  1880. 

Etiologie  und  Pathologic  der  Lepra.     Vierteljahresschrift  fiir  Derma- 

tologie  und  Syphilis,  1884. 

Die  Lage  der  Leprabacillen.     Archiv  fiir  pathologische  Anatomic, 

1886. 

On  the  Heredity  of  Leprosy.     Edinburgh  Medical  Journal,  1890. 

Hardy  :  Article  LIpre  in  Jaccoud's  Dictionnaire  de  Medecine. 

Hawaiian  Government,  Reports  on  Leprosy  to  the.     Honolulu,  1886. 

Hebra  and  Kaposi:  Diseases  of  the  Skin.  Sydenham  Society's  Translation, 
1878. 

Heidenstam  :  Leprosy  in  Cyprus.     The  Practitioner,  1890. 

Hellat,  Peter :  Eine  Studie  uber  die  Lepra  in  den  Ostseeprovinzen  mit  beson- 
derer  Beriicksichtigung  ihrer  Verbreitung  und  Aetiologie,  Dorpat,  1887. 

Helvetius  :  Dissertatio  de  elephantiasi,  1678. 

Hernando  :  La  lepra  en  Granada.  Revista  de  oftalmologia,  de  sifilis,  etc. 
Madrid,  1881. 


678  MOKROW — LEPROSY. 

Hicks,  C.  H.  :  Leprosy  iu  the  Republic  of  Colombia,  S.  A.  British  Medical 
Journal.  1890. 

Hill :  Leprosy.     The  Lancet,  1880.      " 

Hillairet :  La  lepre.     Le  Progres  medical,  1877. 

Hillis,  John  :  The  Lesions  of  the  Throat  in  Leprosy.  Dublin  Journal  of  Medi- 
cal Science.  1890. 

The  Contagiousness  of  Leprosy.     British  Medical  Journal,  1887. 

Leprosy  in  British  Guiana,  London,  1881. 

Hippocrates  (B.C.  400)  :  Works,  translated  (into  French)  by  Littre. 

Hirsch,  A.  :  Handbook  of  Geographical  and  Historical  Pathology,  vol.  ii. 
New  Sydenham  Society's  Translation,  1885. 

Hoegh.  R.  :  Notes  on  a  Case  of  Leprosy.  Transactions  of  the  American  Der- 
matological  Association,  1880. 

Leprosy,  with  Especial  Reference  to  its  Existence  in  Wisconsin,  1888. 

Hoffman  :  De  morbo  illo  maximo — lepra  grsecorum  quae  est  elephantiasis,  1607. 

Hoffman,  Robert:  Leprosy,  with  Report  of  a  Case.  Maryland  Medical  Jour- 
nal. 1890. 

Hutchinson,  Jonathan  :  Fish  Eating  and  Leprosy.      The  Lancet.  1880. 

Remarks  on   Some  Facts  Illustrating  the  Early  Stages  of  Leprosy. 

The  British  Medical  Journal.  1890. 

The  Prevention  of  Leprosy.     Archives  of  Surgery,  1889-90,  and  1899. 

Hyde,  James  Nevins :  A  Clinical  Lecture  on  Antesthetic  Leprosy,  Chicago. 
1878. 

The  Distribution  of  Leprosy  in  North  America.     Transactions  of  the 

Congress  of  American  Physicians  and  Surgeons,  1894. 

A  Clinical  Lecture  on  Tubercular  Leprosy,  Chicago,  1879. 

Impey,  S.  P.  :  A  Handbook  on  Leprosy,  London,  1896. 

Leprosy  in  South  Africa,  London,  1895. 

On  Spontaneous  Recovery  from  Leprosj',  London,  1895. 

Jacoby,  G.  W.  :  Contribution  to  the  Study  of  Anaesthetic  Leprosy,  with  Espe- 
cial Reference  to  Partial  Sensory  Disorders.  Journal  of  Nervous  and  Mental  Dis- 
ease, 1889. 

Jelly,  W.  :  Communicability  of  Leprosy.     British  Medical  Journal,  1887. 

Jones,  Talbot:  A  Clinical  Study  of  a  Case  of  Leprosy  Treated  with  Koch's 
Tuberculin.     Northwestern  Lancet.  1891. 

Joseph,  M.  :  Krankenvorstellung  (Fall  von  Lepra).  Berliner  klinische  Woch- 
enschrift.  1890. 

Kalindero  :  La  l^pre  en  Roumanie.  Transactions  of  the  International  Congress 
of  Dermatology  and  Syphilography,  Paris,  1890. 

Kallock,  C.  W.  :  Leprosy  Affecting  the  Eyes.     Medical  News,  1888 

Kanthack,  A.  A. ,  and  Barclay,  A.  :  Apparently  Successful  Cultivations  of  the 
Bacillus  Lepra;.     British  Medical  Journal,  1891. 

Pure  Cultivation  of  the  Lepra  Bacillus.     Ibid. ,  1891. 

Kaposi :  Article  Lepra  in  Handbucb  der  speciellen  Pathologic  und  Therapie  der 
Hautkraukheiten,  Erlangen,  1872. 

Kaurin,  E.  :  Notes  on  the  Etiology  of  Leprosy.     The  Lancet.  1890. 

Kimball,  J.  H.  :  Leprosy  in  Hawaii.     Occidental  Medical  Times,  1890. 

Kobner  :  Ueber  Lepra.     Berliner  klinische  Wochenschrift,  1885. 

Landre,  C.  :  Sur  la  contagion  de  la  lepre,  Amsterdam,  1884. 

Legrand,  M.  A.  :  La  lepre  en  Nouvelle  Caledonie.  Archives  de  Medecine 
navale.  1891. 


BIBLIOGRAPHY.  679 

Leloir,  H.  :  Traite  theorique  et  pratique  de  la  lepre,  Paris,  1885. 

L^pre   in  the  Article  Trophoneuroses  in   Jaccoud's  Dictionnaire  de 

Medecine,  Paris,  1883. 

Lepine  :  De  rHydrocotyle  asiatica.     Revue  maritime  et  coloniale,  1854. 

Lepre  tuberculeuse.     Lefon  donnee  a  1' Hotel  Dieu  de  Lyon.     Gazette 

Hebdomadaire,  1889. 

Leprosy  Commission  in  India,  Report  of  the,  1893. 

Leprosy,  Fish  Theory  of.     The  Practitioner,  1890. 

Lewis,  T.  R.,  and  Cunningham,  D.  D.  :  Leprosy  in  India,  Calcutta,  1876. 

Lima,  A.  da  Silva :  Hospital  dos  Lazaros,  Relatorio  de  1890.  Rio  de  Janeiro, 
1890. 

Lisboa  :  Papers  on  Leprosy,  Bombay,  1874. 

Liveing,  R.  :  Medical  Times,  1877. 

Elephantiasis  Graecorum  or  Leprosy.     G.ulstonian  Lectures,  London, 

1876. 

Lutz,  A.  :  Zur  Morphologic  des  Mikroorganismus  der  Lepra.  Dermatologische 
Studien,  Hamburg,  1886. 

Mackenzie,  Sir  Morell :  The  Dreadful  Revival  of  Leprosy.  Wood's  Medical 
and  Surgical  Monographs,  New  York,  1890. 

McLeod,  K.  :  Anaesthetic  Leprosy  ;  Nerve  Stretching  ;  Lymphangitis.  Indian 
Medical  Gazette,  1888. 

McNamara,  A.  N.  :  On  Leprosy,  Calcutta,  1866. 

Leprosy  a  Communicable  Disease.     Second  Edition,  London,  1889. 

McNutt,  W.  F.  :  Report  on  the  Etiology  of  Leprosy  to  the  California  State 
Medical  Society,  1887. 

Mericourt,  Le  Roy  de  :  Sur  la  nature  contagieuse  de  la  ISpre.  Bulletin  de 
I'Academie  de  Medecine  de  Paris,  1888. 

Metchnikoff,  E.  :  Qeber  Immunitat  und  Phagocytose.  Fortschritte  der  Medi- 
cin,  1887. 

Mikoy,  Gavin  :  Report  on  Leprosy  and  Yaws  in  the  "West  Indies,  London,  1873. 

Mitra,  A.  :  Treatment  of  Leprosy  in  Kashmir  by  Nerve  Stretching.  American 
Journal  of  the  Medical  Sciences,  1891. 

Montgomery,  D.  W.  :  Microscopical  Examination  of  the  Scar  in  Keanu's  Case. 
British  Medical  Journal,  1890. 

Moore,  Sir  W.  :  Cause  of  Leprosy.     Indian  Medical  Gazette,  1890. 

Moore,  William  :  Nature  of  Leprosy.     Medical  and  Surgical  Reporter,  1890. 

Morrow,  Prince  A.  :  Article  Leprosy  in  the  Atlas  of  Skin  and  Venereal  Dis- 
eases, 1890. 

Article  Leprosy  in   Morrow's   System  of  Genito- Urinary  Diseases, 

Syphilis,  and  Dermatology,  vol.  iii. ,  1894. 

The  Diagnostic  Features  and  Treatment  of  Leprosy.  American  Jour- 
nal of  the  Medical  Sciences,  1894. 

.  The  Clinical  Features  and  Differential  Diagnosis  of  Leprosy.  Ameri- 
can Medico-Surgical  Bulletin,  1895. 

Personal  Observations  of  Leprosy  in  the  Sandwich  Islands.    New  York 

MedicalJournal,  1889. 

The  Diagnosis  of  Leprosy,  Especially  the  Differentiation  of  the  An- 

gesthetic  Form  from  Syringomyelia.  Journal  of  Cutaneous  and  Genito-Urinary 
Diseases,  1890. 

Observations  of  Leprosy  in  tlie  Sandwich  Islands,  Mexico,  and  Cali- 
fornia.    Journal  of  Cutaneous  and  Genito-Urinary  .Diseases,  1889. 


680  MOBROW — LEPROSY. 

Leprosy  and  Hawaiian  Annexation.     Nortli  American  Review,  1897. 

Practical  Aspects  of  the  Leprosy  Question  in  New  York.     New  York 


Medical  Journal,  1896. 

Mouritz,  A.  :  Report  on  the  Leper  Settlement  of  Molokai,  in  the  Report  of  the 
Hawaiian  Board  of  Health,  1886. 

Munch,  G.  N.  :  Lepra  uud  Vitiligo  in  Sud-Russland  und  Turkestan,  Kieff, 
1885-87. 

Contagiousness  of  Leprosy  and  Necessary  Measures  of  Prevention  in 

Russia.     Monatshefte  fiir  praktische  Dermatologie,  1889. 

Munro  •  Etiology  and  Pathology  of  Leprosy.     Edinburgh  Medical  Journal,  1878. 

Mustafa,  Gulani  :  See  Report  of  Phineas  8.  Abrahams  to  the  Epidemiological 
Society  of  London  on  Leprosy  in  the  Punjab. 

Navarro  :  Leprosy  in  Columbia.     The  Stitellite,  1890. 

Neisser  :  Article  Leprosy  in  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine, 
American  edition,  1875. 

Neve,  Ernest  F.  •  Nerve  Stretching  for  Leprosy  ;  Record  of  One  Hundred  and 
Ninety  Operations  Performed  in  the  Kashmir  Mission  Hospital.  Edinburgh  Medical 
Journal,  1884-85. 

The  Propagation  of  Leprosy.     British  Medical  Journal,  1890. 

Newman,  George  :  On  the  History  of  tiie  Decline  and  Final  Extinction  of  Lep- 
rosy as  an  Endemic  Disease  in  the  British  Islands,  London,  1895. 

New  South  Wales,  Leprosy  in.     Australasian  Medical  Gazette,  1890. 

Nina,  Rodriguez  :  A  lepra  no  estado  de  Bahia.     O  Brazil  Medico,  1891. 

Olavide,  JoseE.  :  Del  Contagio  de  la  Lepra.  Rivista  Clinicade  losHospitales, 
1889. 

Sur  la  contagion  de  la  ISpre  et  nombre  probable  de  lepreux  qui  exist- 
ent en  Espagne,  Paris,  1889. 

Orme,  H.  S.  :  Leprosy  ;  its  Extent  and  Control,  Origin  and  Geographical  Dis 
tribution.     Pacific  Medical  Journal,  1890. 

Orvafianos  :  Mai  de  San  Lazaro  en  la  Republica  Mexicana.  Gaceta  Medica  de 
Mexico,  1889. 

Panas  ;  Des  manifestations  oculaires  de  la  16pre  et  du  traitement  qui  leur  con- 
vient.     Bulletin  de  1' Academic  de  Medecine  de  Paris,  1880. 

Peltier,  A.  ;  De  la  l^pre  en  Nouvelle  Caledonie.  Annales  de  Dermatologie  et 
de  Syphiligraphie,  1891. 

Peters,  C.  T.  :  On  the  Treatment  of  Leprosy.  Edinburgh  Medical  Journal, 
1883-83. 

Petersen,  O.  :  Leprosy  and  the  Treatment  of  Lepers  (Russian).     Vratch,  1891. 

Differential    Diagnosis    of    Leprosy.     Transactions  of    the  Russian 

Society  of  Syphilology  and  Dermatology,  1891. 

Phillippo,  J.  C  .  Arrest  and  Cure  of  Leprosy  by  the  External  and  Internal  Use 
of  the  Chaulmoogra  and  Gurjun  Oils.     New  England  Medical  Monthly,  1890. 

Pietra,  J.  :  La  lepra  y  el  hoang-nan ,  su  ineficacia  en  la  curacion  de  la  lepra. 
Gaceta  cientifica  de  Venezuela,  1881-82. 

Plumacher  :  Tlie  Leper  Hospital  at  Maracaibo.  United  States  Consular  Reports, 
1890. 

Poncet  (de  Cluny)  :  La  Ifepre  au-Mexique.  Memoires  de  Medecine  et  de  Phar- 
macie  Militaires,  18(54. 

Pope,  A.  M.  :  Sisters  of  the  Hotel  Dieu  at  Tracadie.  Montreal  Daily  Star, 
quoted  by  The  Nightingale,  1890. 

Pringle,  Robert :  Leprosy  and  Vaccination.     British  Medical  Journal,  1891. 


BIBLIOGRAPHY.  681 

Profeta  •  Sulla  eletantiasi,  Palermo,  1868. 

Quinquaud  :  Etudes  nouvelles  sur  la  Ifepre.     Le  Progrfes  medical,  1890. 

Rake,  Beavan  :  Report  of  the  Trinidad  Leper  Asylum  for  1889. 

A  Case  Illustrating  the  Difficulty  in  Diagnosis  between  Congenital 

Syphilis  and  Early  Leprosy.     St.  Louis  Medical  and  Surgical  Journal,  1890. 

The   Treatment  of  Perforating  Ulcer  in  Leprosy.     British  Medical 

Journal,  1890. 

Protective  and  Antagonistic  Inoculation  in  Leprosy.     British  Medical 

Journal,  1891. 

The  Value  of  Nerve  Stretching  in  Leprosy,  Based  on  One  Hundred 

Cases.     British  Medical  Journal,  1888, 

Rayer  ;  Traite  des  Maladies  de  la  Peau,  Paris,  1835. 

Raymond  :  Histoire  de  I'elephantiasis,  Lausanne,  1767. 

Report  on  Leprosy  to  the  Royal  College  of  Physicians,  London,  1867. 

Rhazes  :  Liber  medicinse  mansuricus. 

Robelin,  Enrique  :  La  Lepra  es  contagiosa.     Cronica  Medico-Quiriirgica  de  la 
Habana,  1887. 

Roux  : Etude Cbimique et Therapeutique de I'Huile de  Chaulmoogra etde I'Acide 
gynocardique,     Th6se  inaugurale  de  la  Facultede  Paris,  Journal  de  Medecine,  1891. 

Russia,  Leprosy  in.     British  Medical  Journal,  1891. 

Samos,  la  Lfepre  en.     Revue  Medico-Pharmaceutique  de  Constantinople,  1890. 

Sawtschenko  -.  Zur  Frage  liber  die  Veranderungen  der  Knochen  beim  Aussatze. 
Beitrage  zur  pathologische  Anatomie,  1890. 

Saxe,  A.    W.  ;    Report  on  Hawaiian  Leprosy.      Read  before  the  California 
State  Medical  Society,  1881. 

Supplemental  Report  on  Leprosy.    Read  at  the  Annual  Meeting  of  the 

California  State  Medical  Society,  1887. 

Schamberg,  J.   F.  :  The  Nature  of  the  Leprosy  of  the  Bible.     Philadelphia 
Polyclinic,  November  19  and  26,  1898. 

Schmidt,  H.  D.  :  A  Contribution  to  the  Pathological  Anatomy  of  Leprosy. 
Archives  of  Medicine,  1881. 

Sentinon,  Caspar  :  Estado  actual  de  la  lepra  en  Espana,  y  medios  de  evitar  su 
difusion.  Gaceta  Medica  Catalana,  1889. 

Sherwell,  Samuel :  On  Leprosy.     Brooklyn  Medical  Journal,  1890. 

Simpson,  Sir  J,  Y.  :  Edinburgh  Medical  Journal,  1841-42. 

Smirnoff,  G.  :  1st  der  Aussatz  austeckend?    Monatshefte  fur  praktische  Der- 
matologie,  1889. 
-    Stallard,  J.  H.  :  The  Leprosy  Bacillus,     The  British  Medical  Journal,  1889. 

Startin,  J.  :  A  Case  of  "True  Eastern  Leprosy"  in  its  Earliest  Stages  Treated 
by  Chaulmoogra  Oil.     The  Lancet,  1882. 

Stevenson,  E.  S.  ■.  A  Case  of  Leprosy  Treated  by  Tincture  of  Eucalyptus      The 
Lancet,  1882. 

Swift,  T.  B.,  and  Montgomery,  D.   W.  :  An  Interesting  Case  of  Anaesthetic 
Leprosy  Apparently  Following  Vaccination.     Occidental  Medical  Times,  1890. 

Swift,  Sydney  Bourne  :  The  Case  of  Keanu.     Occidental  Medical  Times,  1890. 

' An  Interesting  Case  of  Anesthetic  Leprosy  Apparently  Following 

Vaccination.     Ibid.,  1890. 

A  Case  of  Leprosy  Complicated  by  Cancer.     Ibid. ,  1891. 

The  Surgical  Treatment  of  Complications  in  Leprosy.     Ibid. ,  1880. 

Tache,  J.  C.  :  Leprosy  in  New  Brunswick,   1885. 
Tebb,  William  :   Leprosy  and  Vaccination,  London,  1893. 


682  MORROW — LEPROSY. 

The  Spread  of  Leprosy.     The  Homoeopathic  World,  1889. 


Tenier,  E.  :  Ethnographic,  nature,  histoire  et  geographic  de  la  Ifepre.  Bulle- 
tin de  la  Societe  d'Ethnographie  de  Paris,  1887. 

Tennessee,  Report  of  the  Committee  on  Leprosy,  1890. 

Thibi^rge,  Georges  :  Un  cas  de  16pre  systematisee  nerveuse  avec  troubles  sensi- 
tifs  se  rapprochant  de  ceu^  de  la  syringomyelie.  Bulletins  et  Memoires  de  la 
Societe  medicale  des  Hopitaux  de  Paris,  1891. 

La  Prophylaxiede  la  Lepredans  les  Pays  oil  elle  n'est  pasendemlque, 

Paris.  1897. 

Thin,  G.  :  Leprosy,  London,  1891. 

Thouia,  R.  :  Anatomisches  iiber  die  Lepra.  Deutsches  Archiv  flir  klinische 
Medicin,  1890. 

Thompson,  J.  Asliburton  :  A  Contribution  to  the  History  of  Leprosy  in  Aus- 
tralia, London,  1897. 

Tryon  :  Leprosy  in  the  Hawaiian  Islands.  American  Journal  of  the  Medical 
Sciences,  1883. 

Tschirien  :  Archives  de  Physiologic,  1879. 

Tyson,  W.  J.  :  Lepra  Tuberculosa.     British  Medical  Journal,  1883. 

United  States  of  America,  Leprosy  in  the.  Report  of  Committee  to  the  Ameri- 
can Derraatological  Association,  1878. 

United  States  of  Colombia,  Increase  of  Leprosy  in  the.  Abstract  of  Sanitary 
Reports,  Washington,  D.  C. ,  1891. 

Unna,  P.  G.  :  On  the  Microorganisms  of  Leprosy.  Dublin  Jourmil  of  Medical 
Science,  1890. 

Valence,  Poupinel  de  :  Contagiousness  of  Leprosy.  Medical  and  Surgical  Re- 
porter, 1890. 

Vidal,  Emile  :  La  Lfepre  et  son  traitement.     La  France  Medicale,  1884. 

Lepra  nostras.     Memoires  de  la  Societe  Medicale  des  Hopitaux  de 

Paris,  1875. 

Sur  la  contagiosity  de  la  Ifeprc.     Bulletin  de  I'Academie  de  Medecine 

de  Paris,  1885. 

Wachsmuth  and  Bergmann :  The  Contagiousness  of  Leprosy.  Occidental 
Medical  Times,  1890. 

Wahl,  E.  von  :  Ueber  die  Contagiositat  der  Lepra.  St.  Petersburger  medici- 
nische  Wochenschrift,  1889. 

Wcsener,  F.  :  Ueber  die  Uebertragbarkeit  der  Lepra.  Beitrage  zur  pathologi- 
schen  Anatomic,  etc. 

White,  James  C.  :  Question  of  the  Contagion  of  Leprosy.  American  Journal 
of  the  Medical  Sciences,  1882. 

Wilson,  E.  :  On  Diseases  of  the  Skin,  1867. 

Article  Leprosy  in  Quain's  Dictionary  of  Medicine,  first  edition,  1883. 

Wood,  G.  W.  :  The  Dermographic  Effects  of  Introduced  Diseases,  and  Espe- 
cially Leprosy,  upon  the  Havpaiian  People.  Transactions  of  the  International  Medi- 
ical  Congress  at  Washington  in  1887. 

Wright,  N.  P.  :  Leprosy  an  Imperial  Danger. 

The  Spread  of  Leprosy.     British  Medical  Journal,  1889. 

Zambaco  Pacha  :  Contribution  a  I'etude  de  la  16pre  ;  une  enqUete  chez  les  lepreux 
de  Pile  de  Mytelene.  Transactions  of  the  International  Congress  of  Dermatology 
and  Syphilography,  1889. 

La  16pre  en  Turquie,     Bulletin  de  I'Academie  de  Medecine  de  Paris, 

1889. 


BIBLIOGEAPHY.  683 

Les  lepreux  de  Scutari  pr6s  Coastantinople.     Revue  m^dico-pharma- 

cale  de  Constantinople,  1890-91. 

Voyages  chez  les  lepreux,  Paris,  1891. 

Zambaco  Pacha  et  Thibiferge  :  Lfepre  anestbesique  et  syringomyelie.  Gazette 
hebdomadaire  de  Paris,  1891. 

Zuriaga  :  Annales  de  Dermatologie  et  de  Syphiligrapbie,  1889. 

Quelques  mots  sur  les  resultats  qu'on  peut  obtenir  dans  le  traitement 

de  la  lepre.  Transactions  of  the  International  Congress  of  Dermatology  and 
Syphilography,  1889. 

Quelques  faits  de  plus  indiquant  la  possibilite  de  la  contagion  de  la 

l^pre.     Annales  de  Dermatologie  et  de  Syphiligrapbie,  1889. 

Zwillinger,  H.,  und  von  Liuifer  :  Beitrag  zur  Kenutniss  der  Lepra  der  Nase,  des 
Rachens  und  des  Kehlkopfes.     Wiener  medizinische  Wochenschrift,  1888. 

Ashmead,  A.  ;  Alvarez  ;  Babes,  V.  ;  Geill,  W.  M.  ;  GU\ck,  L.  ;  Neisser,  A.  ; 
Impey,  V.  S.  ;  Sticker,  G.  ;  Herman,  C.  L.  ;  Virchow  ;  Besnier,  E.  ;  Darier,  J.  ; 
Kaposi,  M.  ;  Hellat,  P.  ;  Hansen,  A.  ;  Bergmann,  A.  ;  Arning,  E.  ;  Goldschraidt ; 
Jeanselme,  E.  ;  Laurens;  Berillon,  L.  ;  Broesv.  Dort;  Dehio  ;  Zarnbaco Pacha ;  von 
During  ;  Ehlers ;  White,  Jas.  C.  ;  Donovan,  J.  ;  Gemy  and  Raynaud  ;  Orvananos ; 
Canabal  ;  Rat  Numa  ;  Bayet ;  Carrasquilla ;  Raembouck,  E.  ;  Baessler,  A.  ;  Dohi, 
K.  ;  Pellizzari,  C.  ;  Pagerhurd,  L.  W.  ;  Rosalimos ;  Thompson,  J.  A.  ;  Sabadini ; 
Blascho  ;  Schoen,  E.  ;  Petersen  ;  Hallopeau,  H.  ;  Jonkin,  J.  F.  ;  Lassar,  O.  ;  Klib- 
ler,  P.  ;  Neumann,  P.  ;  Grunfeld,  A.  ;  Kalindero,  N.  ;  Petrini,  P.  ;  Mitaftsis,  T.  ; 
Falcao,  Z.  ;  Abraham,  P.  ;  Dyer,  I.  ;  Kitasato ;  Schaffer,  J.  ;  Aristidi  Bey;  Thi- 
bi^rge,  G.  ;  Laverde,  J.  ;  Crocker,  H.  L.  ;  Fornara ;  Atherstone,  W.  H.  ;  Black; 
Sinclair ;  Zuriaga ;  Darier,  quoted  from  Mittheilungen  und  Yerhandlungen  dei 
Internationalen  Wissenschaftlichen  Lepra  Conferenz  zu  Berlin  in  October,  1897. 


^AO 


^ 


l--^^  J 


DATE  DUE 

MAY 

0  970Q1  m^^i 

n\ 

DEMCO  38-296 

ES 


0041068866 


m83 


^.orrow 


